Tag: radiology

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Twelve Red Flags At Your First Post Residency Radiology Job

red flags

 

Unfortunately, not all practices are equal out there. Some abuse the junior employees. Others require responsibilities of their employees that the employer does not outline in the contract. And, even others promise partnership with its employees and do not deliver. So how do you know that your first job is going to work out for you? Well, it can be exceedingly difficult to tell for sure. But, I have come up with twelve red flags while employed or interviewing that will enable you to figure out if you need to move on to a new job or interview elsewhere.

No One Tells You Anything

You show up to work one day and discover that the hospital owners changed the location of your reading area within the imaging center without warning. Or, the private practice partners have a partners’ meeting and are unwilling to divulge any information, even non-sensitive information such as compliance issues for the employees. If this pattern of poor communication continues over time, it is a sure sign that the partners either have poor communication skills or do not respect the employees’ work. Be very wary!!!

Constantly Changing Work Responsibilities

You may be a neuroradiologist, but the practice expects you to all of a sudden read mammograms that you have not read for many years. And, the next week, you are responsible for all the arthrograms, even though you have not done one since your residency. If this happens once or twice, it may be related to staffing or temporary issues. On the other hand, when it is a recurring theme, it may be the first signs of an inept management structure unable to either retain its employees or, perhaps, severe practice disorganization. Think twice about staying!!!

Severe Isolation Syndrome

When you come into work, you see all the offices with radiologists with the doors locked. Just like everyone else, you shut your door too. And, you don’t even hear a peep from another radiologist for days at a time. Is this a collaborative environment? Certainly not!!! It doesn’t bode well for a fruitful, enjoyable long career!!!

No Practice Socialization Events

Most practices have some sort of get-together for the members of the group or hospital, whether it be the attendings, technologists, nurses, or other staff. And, there is a good reason for that. It is essential to get to know your colleagues so that you can feel comfortable relying on them as people. If none of these events are available, it sure seems that a lack of trust may be in the cards. Do you want to be part of a practice where you don’t even know your colleagues?

Hallway Brawls

OK. Perhaps, once in a while, a colleague does not get along well with another. However, if you find this a regular occurrence, there is a good possibility that your colleagues have significant personality disorders. Are you willing to deal with this behavior for the rest of your working career?

No Rewards For Good Employees

Sometimes your employees go above and beyond what the employer expects of them. Practices that ignore good employees also tend to overlook each other. How do you reward someone who is adding value to an imaging business? Well, you give them a bonus, extra vacation, or at the very least essential verbal recognition of their excellent work. If your practice can’t see how good you are and are working hard to better the business, consider going elsewhere!!!

Always Being Told You Are Wrong

Perhaps, you are missing a lot of findings or do not communicate well with colleagues and physicians. But, if you find that you are within the bell curve and your employees are constantly criticizing your work, did you ever think that they might just not want you there? Start looking around!!!

Running Around Like A Chicken Without A Head

Living in constant stress with tons of studies and responsibilities without end is not sustainable over the long run. Some practices run continually by having radiologists read too many cases to be safe. They are just in the business to make money for the bottom line of the partners’ pockets. Can you work in this sort of situation for the rest of your working life? Think about finding someplace where you can work over a long, sustainable period!!!

Lack Of Hospital Involvement

You notice that none of your colleagues or future employers is on committees within the hospital staff. If you want to stay relevant to your place of practice, at least someone needs to be involved. Otherwise, if there is no connection to the practice facilities, the ax may fall when you least expect it, and all of you may be out of a job!!!

No QI Committees

Believe it or not, quality is a crucial element of good practice. How do you know how you are doing? Well, there is only one way. You need to have someone that monitors the quality of the practice. Does the imaging business have morbidity and mortality conferences or peer evaluations? If your future coworkers are embarrassed to have their work checked, you may be looking at a practice that doesn’t care how they are doing. Start thinking about finding a practice that cares about the quality of their work!!!

No One Cracks A Smile

I find it a relief to crack a joke or say something nice and get a good response. However, some practices take themselves way too seriously. Do you want to be in a practice where everyone is miserable?

The Almighty Buck Always Rules The Roost

If you have not learned it yet, you will undoubtedly learn it at some point. It is not always about the money. Employers need to value ethics, practicality, and hard work over money at many points to run a genuinely great practice. If there is never a time that your future employer factors these attributes above the almighty buck, consider your alternatives!!!

So There Are Red Flags. Now What?

Not all practices are perfect, and it doesn’t necessarily mean that they are dysfunctional. However, when you catch a pattern of multiple red flags again and again without correction, it may be time to rethink your employment strategy. Keep your eyes wide open and your ear to the ground!!!

 

 

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The Midnight Radiology Resident Discrepancy

discrepancy

If you haven’t had a discrepancy with the covering morning radiologist as a resident on call, then one of you encountered one of three outcomes. You either haven’t read enough cases. Two, you are the long-lost great-great-grandson of William Roentgen; Or finally, perhaps your name is Watson, the artificial intelligence computer, and you work for IBM!!!

The truth that very few attendings seem to admit is that everyone, including themselves, will miss something every once in a while. One study reported radiologists clinically miss something important between 2-20% of the time. (1) From my experience, that number looks pretty high, but the rate is significant enough. So, when, and notice, I don’t say if you miss something and have a discrepancy at night, you are an ordinary radiology resident. I would even go as far as to say that you are fortunate, in a sense, because you didn’t miss the finding as a full-fledged attending. You have someone to back you up, and hopefully, you will never forget that finding again.

Accepting The Inevitable Discrepancy!

The first step, of course, is to prevent major misses. The cases you need to study leading up to taking calls are the cases that are common and lead to significant morbidity and mortality. You want to view hundreds of different types of appendicitis, aortic ruptures, pulmonary emboli, and so forth so that when the time comes for you to take a call, the chance of missing the critical finding is significantly lower. Unfortunately, however, we can’t prevent all the inevitable misses, and frankly, we have to admit to ourselves first and foremost that this will be the case.

So, what do you do when you have a significant miss? Maybe you sent a patient home with acute appendicitis or a patient with a ruptured ectopic pregnancy. Perhaps you missed an early retroperitoneal bleed. There are specific keys to making the discrepancy in any of these cases, not just another horrible encounter, but rather a learning experience that is valuable for the remainder of your career. We will go through a few rules that you need to follow in the rest of this chapter.

Don’t Perseverate Over The Discrepancy

The first important point is how you emotionally react to the discrepancy. It is also a life lesson. We can’t undo what you did. You need to move on… Perseverating on a miss is counterproductive at best and, even worse, can cause future misses. Remember, just because you made a significant miss does not mean you are or will be a horrible radiologist. So, you need to get over it. The same rules apply to questions on written exams, future failures, etc. One miss does not a radiologist make!

Make Sure To Follow-up The Patient In The Morning

When you find out about the bad news, it is inappropriate to leave the department sulking, not attempting to make good on the miss you made. Try to do what you can to make sure that the physicians in the emergency room know there was a discrepancy. Or, you may need to call the patient back yourself, if need be. Bottom line… You need to make an effort to clean up your mess. It is partially your responsibility.

Read All You Can About the Miss To Not Make the Mistake Again

Reading about the disease, reviewing the films, looking at other similar cases: These are all the things you should be doing soon after the miss. This miss is a real opportunity to understand and fix the incomplete knowledge you had on the subject before, and, of course, to never make the same mistake again.

Teach Others

One of the most rewarding ways of compensating for the discrepancy is to make your fellow residents and junior residents aware of the miss. Teaching your colleagues protects them from making the same mistake that you have made. And, even better, it reinforces the knowledge you have, thereby making it much less likely that you will repeat the same mistake. Just like lightning, it rarely strikes twice!!!

Learning From Midnight Discrepancies

Midnight discrepancies are part of the everyday learning ritual for a radiology resident. It is not the discrepancy itself that is a problem. That is expected and is part of the typical routine residency learning experience. But instead, the issue is how you as a radiology resident learn and grow from the experience. Make the best of a challenging situation!!!

 

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Residency Just Starting And I Am Panicking!

panicking

Hi Dr. Julius,

I read your article on the struggling radiology resident, and it prompted me to contact you. I am an R1 and just finished my first week on Body CT. After this week, I feel panicked and have been attempting to study almost every chance I get, including all day during the weekend. Still, I think I cannot possibly learn all this information (just the anatomy base I need has worried me). I know it is still early, but my colleagues are way more relaxed and comfortable in their current roles than I am. I would greatly appreciate any suggestions you have for me.

Thank you so much for this article and your help,

A Concerned Resident

 

Answer:

Detailing The Problem

To begin, I want to stress that your colleagues who appear as if they are more relaxed and comfortable may be putting on their best face, but they may be panicking too. It can be challenging to tell how another resident or colleague feels. Regardless of how they appear, it would help if you didn’t worry about them. Instead, you must ensure you are doing your best instead of panicking.

I don’t care what anyone says. The first weeks of the first year of radiology are some of the toughest. Anyone who doesn’t think so is in for a big surprise later. It’s good to have a little bit of fear at the beginning. It can motivate a new resident to become great. Excessive fear, however, is no good. You certainly don’t want a fight or flight response!!! Or, you can burn yourself out before you’ve even started. That will make you make you sick.

Also, I think body CT can be one of the more difficult rotations to feel comfortable with, especially at the beginning. Some of the personalities can often be difficult in that field. And, there is more anatomy to know than you may have imagined. This large amount of anatomical information is more so than other subspecialties like nuclear medicine. Plus, you have to start to get to know the pathologies on top of that. So, I know you are in a tough spot.

Solving The Panicking Problem

But alas, there is a solution. I find that the best way to deal with a challenging situation, like the beginning of the first year of radiology, is to establish a reasonable plan of attack. You and I know you cannot know everything. Albeit, many of your attendings may make you feel that way. (you have to try to tune that nonsense out.) However, you can learn what you need to know to become a trusted first-year resident. The key here is to study smartly. Certain books are geared to the first-year resident. For instance, the Webb Body CT book is a great and short resource to learn the basics of body CT scans. You need to concentrate on these.

In addition, the reading style in radiology differs significantly from what you have been learning. Make sure to read the pictures first, the captions next, and then the text last. This strategy will give you the most bang for your buck when reading radiology. Once you have the basics down of a modality within the first week or two, I would also emphasize reading the case review series. Radiology is about pictures. So, why would you not want to emphasize the images? Memorizing lists is daunting and usually not very fruitful without context. Looking at a bunch of pictures makes a list more relevant and memorable. This technique will leave you less prone to panicking. Try to study in this manner.

Also, I would recommend you look at my article on taking oral cases. Handling cases with oral technique is readily transferable to your day-to-day radiology activities. If you can do that well, your colleagues and attendings will appreciate your intelligent assessments more.

In any case, let me know if there is anything else I can help you with. With a bit of change in the study method and trying not to worry about how others look compared to you during your first year (which can make you crazy), I think you can do just fine.

Barry Julius

_______________________________________________________________

Hi Dr. Julius,

Thank you so much for reaching out to me with your advice. I am doing my best to stay positive and study hard. I will let you know how it goes. Thank you!!!

Best wishes,

A Concerned Resident

————————————————————————————————————-

It takes some time to get into the routine. Good luck with it!!!

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10 Ways to Sabotage Your Radiology Residency Interview

radiology residency interview


As radiology attendings, we need to sit next to our radiology residents for hours at a time. We get to know your quirks, mannerisms, and other personality features for better or for worse. (Kind of like a marriage!) Interviews are a time to let that personality shine through. We want to make sure that you are a living, breathing person with a soul. Can you speak understandably? Can you hold a conversation? Are you funny/witty? What’s your hygiene?

A radiology residency interview can also confirm that you are the person you say you are in the application. Can this person be trusted? Is this person going to lie to his attending about a procedure or history? For these reasons, significant weight is placed on the interview even though the process is imperfect. Furthermore, it does not always weed out the bad from the good.

Even knowing the importance of the radiology residency interview process, many prospective radiology residents enter the interview unprepared and have the perceived emotional/situational IQ of a tomato. If that were you, I recommend you practice your advertising pitch numerous times before beginning the interviews. If you want that residency job, you need to be the greatest of actors/actresses during the interview process. Show us that you can handle the demands of radiology residency!!!

Throughout my interview experience, I have seen all sorts of applicant disasters during the radiology residency interview process, usually related to unprepared applicants. Most can prevent these catastrophes with attention and practice. I am going to go through 10 real interview characters that have sabotaged their application. I hope these scenarios will be instructive in the art of the radiology residency interview. DON’T LET ONE OF THESE CHARACTERS BE YOU!!!

The Liar

Our third radiology residency interview candidate of the day walks into the room and shakes my hand firmly as we sit down to talk. He seems very focused, and I enjoy talking with him. He starts talking about how he developed an organization that hires famous CEO guest speakers to come to his medical school and lecture on business in medicine. Wow, very impressive! The interview ran smoothly, so I preliminarily gave him high marks.

After the interview session, the selection committee convenes to review each of the applicants. It turns out, the application and the other interviewer had different stories. Upon review of the application, it says he was just a member of the organization’s club. The other interviewer said he would only chauffeur the CEO to the meeting. Out of concern for the applicant’s integrity, we put him in the do not rank pile.

Bottom line: Make sure to get your story straight. Your oral presentation and written information should all be aligned. The interviewers regularly reconcile everything together. You need to tell the truth and stick with the same story!!

Smelly Guy At The Radiology Residency Interview

Before the formal interview procedure, we have a social interaction period with the residents to get to know the applicants. After most of the residents leave the room, we begin to hear some grumbling from the residents. So, I walk into the room, and as I walk toward a particular applicant, a stench becomes stronger and stronger. Oh my God!! It smells pungent, and I can almost taste it in my mouth. My impulse is to run, but I have to be cordial due to the circumstances. I am dreading the one on one interview process.

Bottom line: Make sure your hygiene is appropriate before starting your interviews. Appearances and “smells” are essential!!

The Sleepy Man

My introductory lecture to our residency program starts, and the lights begin to dim. I typically look at all the applicants in the room to keep the interest level high. But after 5 minutes of lecturing, I hear a loud freight train-like noise emanating from the back row in the form of an applicant in a suit. My assumption is he is not interested in the residency program: suitable applicant but low-interest level. We rank him toward the bottom of the list.

Bottom line: It is imperative to get a good sleep the night before the interviews. Even if the applicant was only tired but interested in our program, sleeping during the interview shows a lack of interest and respect.

Ms. Robot

I warmly introduce myself to an applicant as she enters the room for the formal interview. Entirely devoid of emotion and empathy, she responds, “Hi” quickly. We sit down, and the applicant immediately launches into this speech about herself without any voice inflection or changes in tone or speed. I have the sense she has done this a thousand times before. There is no “conversation-like” tone to her speech. No interactive quality. Is this the way she will behave when I have to sit with her for hours at a time? Even though her application was excellent, the applicant committee decided to give her a do not rank assessment.

Bottom line: Practice interviewing with others. Pretend you are having a conversation and interacting with your interviewer. Perceived personality is vital!

Shy Radiology Residency Interview Guy

The applicant walks into my interview room and introduces himself, but I can barely hear what he says. He stretches out to shake my hand. His hand feels cold, limp, clammy, and weak. The interview starts, and I try to get him to respond to my questions, but it’s like “pulling teeth.” The answers last 10 seconds at most. I asked the residents sitting next to him in the conference room about the candidate, and they said he didn’t speak a word. No one was able to figure out his personality. Even though his application was OK, we felt we could not put him on the rank list.

Bottom line: You need to get over your fears and act and speak with confidence. It may involve practice, coaching, and psychological evaluation. If we can’t figure out who you are during your interview, we are not sure if we want to sit next to you as a resident!!!

Mrs. Bizarro

Across from me in the interview area sits a pleasant-looking woman dressed appropriately. Everything seems fine until our conversation begins. Her eyes start to bulge out. Smiles and giggles burst out inappropriately in the middle and end of sentences. Even though she answers my questions mostly appropriately, something is off.

After the interview, we meet with the selection committee, and the first thing I ask is: what’s with Mrs. Bizarro? All the committee members look at me and say, “We were thinking the same thing!!!” We quickly took her off the rank list.

Bottom line: Practice your interviewing skills in front of a mirror or tape yourself on an iPhone. You need to know that your expressions are appropriate for the interview context. This lady may have been an excellent radiologist, but we sure would not feel comfortable having her sit next to us!!!

Not Quite Right, Joe

Toward the end of the interview, we start to talk about extracurricular activities and hobbies. The applicant proceeds to say that he was into cow-tipping as a college student. And one time, the college dean reprimanded him for the activity. Automatically, mental bells start ringing. Who would mention something like that in an interview setting? Why would someone want to do that to a cow? Off the rank list, he goes!

Bottom line: We are not your friends in the interview setting. Do not release any information that could jeopardize your application and make you appear strange. We do not want any issues during residency that could cause probation, suspension, or worse!

The Guy all the Residents Hate At The Radiology Residency Interview

I am having a great conversation with one of the applicants. He tells me about some of his exciting research projects and hobbies. He seems to be a straight shooter and is very witty. We end the conversation on a high note with expectations that we will rank the candidate highly.

After our interview, we met with the rest of the admissions committee. The admissions committee consists of the residency director, associate residency director (myself), chief resident, and several other senior residents. We begin to discuss the candidate at hand. Every single resident states something negative like: “This guy was obnoxious”; ‘He was chauvinistic,”; “Really bitingly sarcastic.” The directors are dumbfounded. We place the applicant in the do not rank pile.

Bottom line: You need to play nice with all members of the staff, especially the residents. They have essential input in the residency application process and interviews. The wrong statement can get you kicked off the rank list!!!

The Cell Phone Gal

I started giving the introductory talk to the applicants about the program. Every minute or two, I notice a woman looking down at her lap. Oh well… I continued with my lecture.

An hour later, we meet for an interview, and we shake hands. We sit down, and I start asking questions. The applicant seems a little bit distracted. Again her eyes continue to float down toward her lap every few minutes. All of a sudden, I hear a ring. She picks up the cell phone and says to me, “I need to get this.” She is not interested in our program.

Bottom line: Shut off your cell phone. You are here to interview for a job. It is a sign of disrespect to use your cell phone at any time during the interview process!

Opaque Sam

We parse through an applicant’s resume and ERAS transcript. The package states that the resident had a DUI arrest when he was a college student. So, the interview begins after some ice-breaking small talk. Naturally, a DUI arrest is a big deal. It signifies that the applicant has the potential to be an alcoholic and engage in risky behaviors. So, I anxiously pop the question: Tell me about what happened with your DUI arrest when you were in college? The applicant bluntly states, “It happened. It’s over. I don’t really want to talk about it further…” A moment of silence ensues.

Flash forward to the selection committee meeting. All the interviewers received the same response from the applicant. There was no response of remorse. No explanation for the event. Nothing. Our committee put the applicant in the do not rank pile.

Bottom line: Candidates should address any adverse events upfront, or else an admissions committee may perceive the applicant as hiding something significant, whether true or not. Don’t be like Opaque Sam!!

 

Sabotaging Your Radiology Residency Interview!

Interviewing is often about what not to do as much as it is what you should say. Make sure you prepare for the interview day. And, don’t be like our ten catastrophic characters!!!

 

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Is It Possible To Get Into Radiology Residency With An H1B Visa?

Good evening, I am an MS3 just starting to discover the excitement of radiology on my radiology selective. I am contemplating radiology as a career, but I have low Step 1 score (227) and I am also an international student requiring H1B visa for residency (I attend a top 40 US allopathic school and am not Canadian). Is radiology still an option realistic to consider given my circumstances (I hope to match into a university program)? What can I do now as I start my third year going forward to increase my competitiveness? Thank you for all your help!

Adele

Hi, Adele!

H1B And J1 Visa Issue

The answer to the question of your chance for getting into a program may hinge on the next few questions I am going to ask you. Why is it that you require an H1B vs. a J1 for getting a residency? What kind of visa do you currently have? This may make a big difference because universities are much less likely to support a resident with an H1B visa since it costs the university a lot of legal fees and time to support a candidate to obtain the H1B visa. Also, the federal government limits the numbers of H1B visas. Therefore, you significantly limit the playing field of choices of programs to apply.

Some of the larger academic university programs may allow applicants with an H1B visa. But, many smaller programs like ours do not take applicants with H1B visas for the reasons I mentioned (with a few rare exceptions). When applying, if you can’t get a J1 visa, I would definitely call the individual programs to see which ones would take an H1B visa.

Biggest Positives In Your Application

So, what do you have going for you? First, the fact that you are graduating from an American medical school will help your situation immensely. We, as program directors, selfishly like to get applications from American medical schools. At least we can vouch for the quality of the institution and compare to other applicants. Second, your scores are not bad. Many programs have cutoffs around 220 or 225. So, it should allow you to meet that requirement at many programs.

Other Recommendations

In addition to the recommendations above, I would also consider taking the next USMLE early, studying hard, and perhaps completing a USMLE Step II course so that you can show improvement from your 1st USMLE examination to the next one. Program directors like to see improving scores going in the right direction.

Why The Visa May Be The Biggest Issue

Unfortunately, the visa issue may the biggest impediment to getting a radiology residency slot. I would like to refer you to my article called The Alphabet Soup Of Residency Visas And The Radiology Alternate Pathway: A Guide For The Foreign Radiology Residency Applicant at the link above:

Thanks for the great question. I would be specifically interested in why you need an H1B. Let me know if there is any other information that you think I can help you with. I will post it on the website at some point because I think it would be useful for other applicants in your situation as well.

 

Regards,
Barry Julius, MD

Dear Dr. Julius,

Thank you for your reply and great advice.

I am currently on an F1 student visa and was advised against a J1 visa by my immigration attorney because of the requirement to return to my home country for 2 years. I am Singaporean and have been looking into the H1B1 visa for Singaporeans. It is similar to H1B, but has its own cap that has never been filled historically, can be obtained anytime throughout the year, and only requires the employer to file LCA (I-129 is not needed).

I am under the impression that it would be easier to approach programs that offer H1B already to ask about sponsoring for H1B1 visa, than programs that offer J1, since they may not be familiar with the H type visa. Is this likely to be true?

Also, how and when would you advise me to contact programs and discuss visa-specific issues/requests. Should this be done before I submit my residency application?

Thank you for all your help.

Best regards,
Adele

 

 

Thanks for the additional information. That allows me to understand the issues that you have and why you need an H1B1.

I would definitely make sure to contact the residency programs and the Graduate Medical Education (GME) office prior to applying because many of the programs will not even look at a candidate who has to get an H1B or H1B1 visa for a residency slot. Most programs are set up for the J1 visa. If you need an H1B or H1B1 visa to get into a program, it puts you into a different application pool.

You certainly don’t want to waste your time and money applying to those programs that only take J1s and not H1Bs. It makes sense to contact each of the individual radiology programs and the GME office prior to applying to save you a headache. Typically, the person to speak with would be one of the folks in the GME office who handles visa issues. And, you probably want to speak to the residency coordinator because occasionally the individual program policy can potentially differ from the GME office. ( the program may not take a resident with a visa issue, but the GME office may say it is OK) At our institution, this person is a secretary and is very knowledgeable about all things visa related since she has been doing it for a long time.

Hope that gives you a little bit more insight about when to contact the program and who to contact.

Regards,
Barry Julius, MD

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How to Choose a Radiology Fellowship

radiology fellowship

For some people, choosing a radiology fellowship is easy. They may have known they wanted to be an interventional radiologist or pediatric radiologist since they were two years old. But, for the majority of us, it is a more challenging decision. And it is a decision that you cannot take lightly. It has a direct effect on the type of practice (generalist or specialist), your lifestyle (academic vs. private practice), location (rural vs. urban), the types of people that you will see daily (direct patient care vs. indirect patient care), and more!

So, I have come up with some guidelines for making this agonizing choice. Consider basing this decision on your personality, what kind of lifestyle you want, the desire to make a little bit more money, the need to be in a particular location, application competitiveness, and gamesmanship/trends in the different subspecialties. I will divide the radiology fellowship decision tree into these six parts and describe how you should utilize each factor to choose your future subspecialty area. Let’s start with the first factor.

Personality:

You can’t deny who you are, and you can’t let others make that decision for you. If you hate working with your hands, interventional radiology will not be for you, regardless of your attendings’ opinion of your performance. It behooves you not to decide to enter the field because you will be doing what you hate. Likewise, if you don’t like patients, mammography is undoubtedly not an appropriate specialty, even if you are adept with people. When you consider your personality type, you’ve already significantly limited the playing field.

I will list several personality types and make a list of the appropriate possible specialties for you. Your personality type may differ from the ones listed below. If that is the case, you should think about your personality type and develop a different cluster of several fellowship options.

Gregarious and outgoing- General Radiology, Interventional Radiology, Mammography, Pediatric Radiology

Fiercely independent- General Radiology, Interventional Radiology, and Neuroradiology

Introvert- Body Imaging, MSK Radiology, MRI, Trauma and Emergency Radiology

Jack of all trades- Body Imaging, MRI, Nuclear Medicine

Likes working with hands/interventions- Body Fellowship, Interventional Radiology, Mammography/Women’s Imaging

Nurturing and friendly- Mammography/Women’s Imaging, Pediatric Radiology

Techie- Body MRI, Informatics, Interventional Radiology, Neuroradiology (Interventional and Nonintervention), Nuclear Medicine

And so on…

Lifestyle:

So, you’ve decided upon your personality type… The next issue is what kind of lifestyle do you want. When I mean lifestyle, I am thinking about the following factors. Do you want to be academic or non-academic? Are you interested in becoming the “go-to-guy” for your specialty because you know a specific subspecialty in-depth? Do you mind being on call late at night? Do you want to be in a small or large practice? So let’s go through each fellowship option and determine the lifestyle factors of each of these subspecialties. Add these factors to the personality factors to hone your choice of subspecialty further.

Body Imaging/MRI-

Most often practices general radiology without mastery of a single subspecialty area, Allows for academic and non-academic possibilities, Can practice in a very small or large practice.

Cardiothoracic Imaging-

Most often, practices in his/her subspecialty in an academic and large institution, Master of a single subspecialty.

Informatics-

Needs to work in a large or academic center, Allows for the increased possibility of entry into the business domain, Master of individual subspecialty

Interventional Radiology-

Allows for performing general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic, Tendency for long call hours

Musculoskeletal Imaging-

Allows for the practice of general radiology or mastery of individual subspecialty, Allows for small or large practice, Can be clinical or academic

Neurointerventional Radiology-

Most often, practices in his/her subspecialty in an academic and large practice, Master of a single subspecialty, Tendency for long call hours.

Neuroradiology-

Can work in a large or small practice, Can be academic or non-academic, Master of individual subspecialty

Nuclear Medicine-

Tends to be situated in a larger practice. Can be academic or non-academic; most often is a generalist.

Pediatric Radiology-

More often, academic or related to a large practice. Maybe more predisposed to nighttime calls (i.e., intussusception reductions), Master of a subspecialty

Trauma/ER radiology-

Most often in a large or academic practice, most often a generalist, Tendency toward nighttime work.

Women’s Imaging/Mammography-

Has more options for part-time hours and fewer calls. Can be academic or clinical, Can be in a small or large practice, Master of individual subspecialty, and less likely to be a generalist.

Money:

Fortunately, you’ve entered the radiology world, and all of its subspecialties within the United States tend to be higher paying than most other specialties. And, the distribution of salaries (1) is relatively equal among all subspecialties. However, there is a slight discrepancy/increased income in the interventional-based subspecialties such as Interventional Radiology and Neurointerventional Radiology, mostly based on the amount of time working rather than bringing in more revenue. Money should, therefore, play a minor role in the decision tree.

Location:

Location can be an essential factor in choosing a fellowship subspecialty because some fellowships may limit you to larger cities and academic centers. Take this into consideration if you need to be in a more rural locale for family reasons. Remember this issue if you want to practice in the more academic subspecialties of Cardiothoracic Imaging, Informatics, Interventional Neuroradiology, Nuclear Medicine, Pediatric Radiology, or Trauma/ER radiology. Location preferences can potentially whittle down your choice of subspecialty further.

Application Competitiveness:

Competitive subspecialties frequently cycle over the years. For example, when I was a resident considering a fellowship in 2002, you couldn’t find anyone to enter the interventional radiology subspecialty. Programs were desperate and would take anyone that graduated. Meanwhile, in 2014, the same specialty became an ultra-competitive fellowship, and our residents had to send out numerous applications for the same spot. Therefore, if you have not performed well during your residency program or come from a smaller program, you may have some difficulties entering a more competitive fellowship in some of the more competitive areas. Do not despair, though. Most of the time, you can get into one of these more competitive areas. You need to send out more applications and use your connections to your residency program.

Based on my recent experiences, some of the more competitive subspecialties in 2015 and 2016 include MSK Imaging and Interventional Radiology. But of course, that can change in any given year. You should still try to get into the more competitive specialties if that is what you desire. Just have a backup plan.

Trends/Countertrends:

So you’ve gone through the first five deciding factors, and you probably have whittled down your choice substantially, but you’re still not sure. There is still one more thing that you should probably consider before making your final decision for a radiology fellowship. There are currently two secular areas of significant growth within radiology: big data/data processing and increasing applications of MRI.

Then, consider this. You are probably better off picking an area of growth than one that may be more cyclical and subjected to the economic cycle’s vicissitudes. It is simple job security. Informatics and the MRI-based specialties certainly meet these criteria.

Also, I have found over the recent history of radiology, you are better off going against the grain, just like a contrarian investor in the stock market. You may consider in 1996, when Bill Clinton was talking about the socialization of health care and health care capitation, radiology became extremely unpopular. Those same residents that applied to radiology around that time had a fantastic choice of places to work. Also, they could command their salaries at the highest rate. And, most remarkably, they found work in the most desirable locations when they graduated in 2001-2003.

On the other hand, when radiology was extremely popular in the mid-2000s, many excellent radiology applicants applied. Those same residents graduated in 2009-2012 and were very limited in their job prospects. The same situation will likely hold for many of the less popular subspecialties at the current time. Take the contrarian view into consideration as well.

Summary About Choosing A Radiology Fellowship:

Using these criteria, you should certainly be able to narrow down your choice of subspecialties to one or two different possibilities at the most. Good luck with your final choice!

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How To Create A Killer Radiology Personal Statement

radiology personal statement

 

Personal statements in the radiology field are the least effective way to bolster your application. (1) Rarely, do they help an applicant. Occasionally, they hurt the applicant’s case. Regardless, I am aware that the personal statement will often become essential to many viewers of this article who apply to radiology regardless of whatever I say.  Therefore, I am creating this blog for anyone that is applying for a radiology related job to learn to create that killer radiology personal statement. And, today I am going to recount some of the basics for creating one. Specifically, I am going to start by explaining the parts of a great radiology personal statement and then give you some general tips that I have learned over the years from blogging and reading many personal statements.

First Paragraph:

The Hook

After having rummaged through thousands of radiology personal statements and writing lots of blogs, I can definitely say that the key paragraph for the reader begins at the beginning. If it is average/boring, I have almost zero desire to read the rest of the statement, especially when you have another 10 more to read that day. Something in the few first few sentences needs to draw the reader in quickly. You are not writing a short story or novel where you can slowly develop your characters and plot. Rather, you need to write using a technique that I like to call the hook. Reel that program director in.

There are several techniques that I have seen over the years. Let’s start by using the writing technique of irony. Notice the irony I chose in the first paragraph of this article. I started by saying personal statements are the least effective way to bolster your application. Whoa, wait a minute! The title of the article is How To Create A Killer Personal Statement. That’s somewhat interesting. The dissonance in that first paragraph draws the reader in.

So, what other techniques can you use to maintain the interest of the reader? Sometimes quotes can certainly help. Once in a while, I come across a quote that really interests me. I tend to like quotes from Albert Einstein. They tend to be witty and have double meanings. But, there are certainly millions to choose from. A good quote can set the tone for the rest of the personal statement.

Finally, you can write about an interesting theatrical description of a life-altering event that caused you to want to go into radiology. Use descriptive novel-like adjectives and adverbs. Go to town. However, be careful. Don’t choose the same events as everyone else. Read my other blog called Radiology Personal Statement Mythbusters to give you some other ideas about what not to choose!

Tell Why You Are Interested In Radiology

The first paragraph is also an important place to tell the reader why you are interested in radiology. Many times I will read a radiology personal statement and say to myself that was kind of interesting, but why does this person want to go into the radiology field? He/she never quite answers the question and I am left feeling that this person does not know why they want to enter the field. Don’t let that be you!

Second Paragraph:

Explain Any Problems/Issues

I like the applicant to be upfront with the reader rather quickly if there was an issue that may cause a program director or resident to discard an application. It could be addressing something as serious as a former conviction for drunk driving when you were young and stupid. Or, it could be something milder like a questionable quotation from a mentor that you found in your Deans Letter. Either way, you need to explain yourself. Otherwise, the problem/issue can declare itself as a red flag. Subsequently, it can prevent you from getting the interview that you really want.

Second and Third Paragraphs

Expand Upon Your Application

Let’s say you don’t really have any red flags in your application. Well then, now you can write about some of the things that you accomplished that you want to bring to the attention of your reader. Typically, these may be items in your application that are partially explained in the experience or research sections of the ERAS application but really deserve further emphasis or explanation.

Show Not Tell

In addition, the meat of any personal statement should contain information about what you did. Do not, instead, describe all the characteristics you had to allow you to do it. This is a cardinal mistake I often see in many personal statements. What do I mean by that? If you have been working at NASA on the Webb Space Telescope, you don’t want to say I was a hard worker and was well liked by everybody. Rather you would want to say I spent 1000 hours building the mirror for the telescope constantly correcting for mistakes to such a fine degree that the engineering societies considered it to be almost perfect. And to show you were well liked by everybody, you can say when you were done completing the telescope, NASA held a ticker tape parade for me!!! (Well, that’s probably not the case. But, hopefully, you get the idea.)

Final Paragraph

Time to Sum Up

This can be the most difficult part of writing a personal statement (and blog too!) How do you tie everything together into a tight knot so that everything comes together and makes sense? Well, one thing you can write about is what you will bring to the table if your residency program selects you based on what you have stated in your radiology personal statement. Back to the Webb telescope example: Given my experience with my successful quest for perfection by creating an almost perfect telescope mirror, similarly, I plan to hone my skills to become an incredible radiologist by always learning from others and my fellow clinicians to get as close to perfection as possible. Bottom line. You want to make sure to apply your experiences to the job that you want to get.

General Issues With Editing

1. I have learned a few things about writing over the past years, whether it is blogs, personal statements, letters, or whatever else you need to write. However, the most important is the obsessive need to review and re-review whatever you are writing for editing. It may take 100 edits to get it right!!!

2. Have a friend or a relative read your personal statement to catch errors you may not see. Your brain is trained to already know what you have written. Many times the only way to catch your own mistakes is to have another person read your writings.

3. Also, make sure to the read the personal statement out loud. Sometimes you can only detect errors by listening to what you have actually written. It happened many times when I edited my book Radsresident: A Guidebook For The Radiology Applicant And Radiology Resident

4. Finally, I recommend the use of grammar correcting programs. The one that I would like to bring to your attention is the program called Grammarly. I am an affiliate of Grammarly. However, that is only because I use the program myself for my blogs all the time. It has saved me from really stupid mistakes. One version is for free and corrects simple critical errors. The other uses more complex grammatical corrections and is a paid service. Regardless, either version will assist you in catching those silly errors. In addition, I usually paste my blogs into the Microsoft Word program to correct any other possible errors. I have found both programs to be complementary.

Other Useful Tidbits

Avoid Too Many I Words

When writing a radiology personal statement, try to reduce the usage of the word I for multiple reasons. First, it begins to sound very redundant. Second, you appear selfish. (It’s always about you, isn’t it?) And finally, you want to create the impression that you are going to be a team player, not in the field of radiology just for yourself.

Active Not Passive Tense

If you want a passage to sound great, make sure to almost always use the active tense, not the passive variety. When using the passive form, the reader has more work to do because he/she has to figure out who is doing the activity. In addition, the environment appears to control you rather than you controlling the environment. And finally, sentences sound more verbose when using the passive tense. Think about the following phrases: The job of creating a computer algorithm was completed over the course of 10 years vs. My colleagues and I created a computer algorithm over the course of 10 years. Which sounds better to you?

Use Sentence Transitions

If you want your personal statement to sound smooth, I find words other than the subject at the beginning of the sentence help to diversify the sound of the individual sentence. Also (notice this transition word!), it allows for a change of idea without being so abrupt.

Don’t Use The Same Word At The Beginning Of Each Sentence

In that same train of thought, try not to use the same word to begin a sentence over and over again. It’s a surefire way to bore the reader!!!

Creating That Perfect Radiology Personal Statement

Now you know some of the rules I would utilize to create an interesting radiology personal statement. Some of these are general rules that I apply to my blog on a weekly basis that I also see in the best personal statements. Therefore, I know that they work well. So, go forth and write that killer radiology personal statement. You now have all the tools you need!!!

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Cracking the Radiology Residency Application Code

application

Most medical students and residents do not have an insider’s insight into radiology residency and fellowship application and interview processes. Even worse, misleading advice and rumors cloud the process. One needs only to look at the average student or residency forum to see numerous conflicting stories and statements.

Only someone actively involved in the process can understand what you need to know when applying for a radiology residency. So, thankfully, you have come to the right post. I have looked at thousands of applications and interviewed hundreds of residents for positions in our program as associate program director. So, I will help you out by delving into the depths of the radiology residency application process. This article will give you the basics of what you need to know.

The Application

We could go through the application in one of many ways. But, I think the best way is to go through the different parts of the application from most to least important. This way, you will not squander your energy on the small stuff!

The Dean’s Letter

Few sections of the application genuinely differentiate one applicant from another. Dean’s letters happen to be one of those items. The reason for that: you will receive comments from attendings, residents, nurses, technologists, and secretaries that may say something negative. I can’t tell you how often we have parsed an entire application with glowing positives until we arrive at the Dean’s letter. And, then we receive coded messages in the letter, such as: was very shy during the rotation, but did see some improvement. Or, this resident was very independent. However, he did not seek help when presented with a challenging patient care issue. And so forth.

Additionally, the Dean’s letter is the only document (other than the boards) that compares the applicants to their classmates. Most medical schools have buzzwords indicating the residents’ rank in their class. Each one is different, but typically it allows insight into which quartile the resident resides.

Can You Do Anything About The Dean’s Letter?

Ok, so you have your Dean’s letter written in “stone.” And, at some institutions, you may hear that administrators say you cannot change the Dean’s letter. But usually, at the bare minimum, you can check the Dean’s letter. All medical students applying for a residency should scan their Dean’s Letter before sending out the application. I have seen Dean’s letters sent on behalf of medical schools with the wrong applicant’s information!

At other institutions, you can look at your letter before application time and potentially modify the document. If that is the case, you should undoubtedly check it for any hostile or questionable comments. And then, if possible, confront the department/person that wrote the statement. Ask if they could redact or modify it. If the writer is truthful, the person may decide to leave it there. But an attempt should be made, as this one negative comment can make the difference between high, low, or no ranking on a program’s rank list. Not infrequently, the admissions committees will obsess over one questionable comment. They will often spend countless painful hours perseverating over these “minor details.”

The institution may not allow you to look at the Dean’s letter at a few medical schools. But the school may allow your mentor or a faculty member to look at the document and possibly edit it for corrections. I can’t emphasize enough how important it is to increase your odds of being accepted to the residency of your choice.

The Boards/USMLE

Why are the boards important? Well, the boards/USMLE assess the ability of a future resident to pass the radiology certification examinations. We have noticed a strong correlation between lower board scores and difficulty passing the new core exam in our program. So, similar to our program, most programs take the USMLE score very seriously.

In addition, programs use board scores more as a baseline cutoff. Once you score higher than that baseline, it doesn’t factor much into the ranking equations. On the other hand, unless extenuating circumstances exist, failing and low scores usually place the application in the deny pile.

What About COMLEX?

For those of you that are D.O. medical school applicants, I recommend that you take the USMLE in addition to the COMLEX examination. Many radiology programs are unsure of the significance of COMLEX scores and don’t know how to factor the scores into the ranking equations/cutoffs. Applications with COMLEX scores alone may get thrown out of the interview pile entirely.

Gamesmanship

Even with all these factors, you can use some gamesmanship when it comes to the boards. If you have done very well in the step 1 boards, often, you may be able to get away with just sending those scores alone. You may want to delay taking step 2 USMLE. With high USMLE Step 1 scores, USMLE step 2 scores can only hurt you if they are lower. Of course, all this gamesmanship will disappear when the scores no longer exist on Step 1. At that point, Step 2 scores will most likely replace the outcomes on Step 1.

Finally, most programs look for/expect improvement from step 1 to step 2, especially with borderline step 1 scores. So be careful and take the step 2 boards very seriously. Invest in a review course if you need to.

Research

Nowadays, research can become a significant factor in getting an interview in a residency program. What is the reason for that? ACGME guidelines mandate that accredited radiology residencies have specific radiology research requirements for residents before graduating. Knowing that a resident has completed multiple quality research projects means that a resident can work more independently completing research projects. This knowledge of research reduces the burdens upon the department.

Furthermore, radiology research may demonstrate significant interest in the field. And, it provides an avenue for discussion during interviews later on in the process. We often look at an application, saying it’s pretty good, but the resident hasn’t completed any research. That may take the application down a few rungs.

Bottom line, though. It won’t take you entirely out of the running for getting a spot. However, it can be a significant asset in some situations.

Extracurricular activities

We look for two big red flags to avoid on this section of your application: those applicants that emphasize that they have participated in every extracurricular activity under the sun and those applicants who write down almost nothing. A resident who participates in everything suggests that he lacks focus, never investigating or accomplishing tasks in depth. On the other hand, a resident that engages in nothing but school tends not to be well rounded. These residents may not have outlets to disperse their frustrations during their four years of training. A residency director does not like having frustrated residents!

Impressive Extracurriculars

So what are some activities that impress the admission committee? : Interesting extracurriculars that show leadership potential, activities that demonstrate a depth of involvement, and activities that offer an ability to handle stressful situations and function independently. Some of the special extracurriculars that stand out in my mind that meet these criteria would be a student that started a Subway franchise successfully from scratch and made it into a big business, a student that participated in the Olympics, and a student that lobbied for Congress. These are people that tend to climb the rank list higher because their extracurriculars were memorable.

Not So Memorable Extracurriculars

What are some extracurriculars that don’t add much to the application? Those activities that everyone else does and do not suggest leadership potential. In radiology, those would include participating in a radiology club (Big deal!), participating in health fairs (Every medical student does it), and teaching inner-city kids (We see it all the time as part of medical school curricula!) Not that these activities are harmful, but they don’t add much at all to your application. My recommendation to you: find something you enjoy, hopefully, something unique, and stick with it during your four years of medical school training!

Recommendations

Admissions committees like to make a big deal about recommendations. You’ll undoubtedly hear that you need an excellent letter to get into a great program. But honestly, if you ask someone for a recommendation, it is unusual to find someone who will write you a nasty one. Students are going to ask attending physicians that like them. On the other hand, although rare, we see a “bad” recommendation as a significant red flag. It often means the resident that obtained the letter has a poor emotional intelligence quotient. Or she couldn’t find one attending that liked them- both significant issues!!!

Like the rare bad recommendation, great recommendations that raise the application within the pile to a higher rank are also unusual. For the most part, this type of recommendation stems from well-known entities that want the person in their program. Or perhaps, it comes from a close colleague that the radiology admissions committee implicitly trusts.

Recommendations rank relatively low in the application influence equation given the rare ability to change the application disposition.

The Personal Statement

Finally, I would like to talk about the item that medical students often perseverate on the most: the personal statement. The personal statement seldom helps an applicant and can occasionally hurt an applicant. After having read over a thousand of them, there are very few standouts. And, almost all of those that stood out were somewhat disturbing. I still remember an essay that emphasized a dead rabbit. It did not have any correlation to radiology whatsoever. I was concerned about mental illness in that student. We terminated the possibility of acceptance to our program immediately!

If I had to say one thing, I would advise you to be cohesive and relevant to your future career as a radiologist. Also, watch out for typos because typos suggest an inattentive personality, not a characteristic you want in a radiologist. Other than that, don’t fret too much about this part of the application.

Summary

Application for radiology is an arduous process with multiple pitfalls. Make sure you concentrate on those items that give you the most “bang for your buck” to send your application higher on the rank list. In particular, put particular emphasis on the Dean’s letter. Check it if you can. Correct it if need be.

And finally, don’t be that student with marginal board scores, no research, dull or no extracurriculars, poor recommendations, and a personal statement that stands out too much. If you follow my suggestions and try not to rock the boat, you should get into a great residency!

 

 

 


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Maintenance of Certification (MOC)- A Controversial Necessity?

MOC

A groundswell of controversy about maintenance of certification (MOC) has been building slowly for the past decade. In truth, no quality evidence-based study has shown a link between quality of care and MOC. Therefore, multiple entities in the United States are abuzz, attempting to create anti-MOC legislation to prevent boards from gaining a legal foothold in states requiring MOC for practicing medicine. Some of you may hear about these issues in the press. (1,2) These issues are not just unique to radiology.

But before we discuss the individual controversies, we need to delve into MOC a bit further, especially for those just starting. What exactly is the maintenance of certification once you complete your residency in the United States? What do you have to do to satisfy the requirements? Why do you need to meet the requirements for MOC? And when do the requirements for maintenance of certification begin? Some of the answers to these questions are not so obvious. So, these are some of the questions I hope to answer in this post.

What is MOC?

According to the “experts,” maintenance of certification is a way to show that you are continuing to keep up with the educational demands of your specialty. Theoretically, it should ensure continued minimal competency to practice medicine. The American Board of Radiology and your state of practice require specific essential documentation for diagnostic radiology. For instance, the ABR requires 25 hours of continuing education credits (CME) per year, passing a test every ten years or completing online email questions correctly to certify competency, verification of state licensure, and quality improvement projects or leadership roles.

Individual states also require their primary means of determining competency to maintain licensure. When I first obtained my license in New Jersey, I had to take a required orientation course. Every year, I need to submit 50 CME credits each year. In addition, the state requires me to satisfy an end-of-life care course requirement every three years. Each state can significantly differ in what is needed to keep a license. Go to the site called mycme.com for more information on your particular state.

How Do I Get CME Credits?

Typically, radiologists can get continuing medical education credits in one of many ways. First, many online radiology society websites, such as RSNA and ARRS, develop education portals for radiologists to complete either articles or lectures. The radiologist then takes a short quiz they must pass at the end of the episode to document that he has completed the task.

Second, you can attend conferences at many locations throughout the country and then collect the CME credits at the end of the course. Usually, the conference presents the physician with a certificate of completed CME at the end of the meeting.

And then, internally within your hospital or practice, you can participate in tumor boards, conferences, etc. Subsequently, you can obtain the CME credits after documenting what you have experienced as long as the creators of the conference have applied for CME.

What Happens If I Don’t Participate In MOC?

Unfortunately, for most radiologists, it is not an option to forgo MOC. Most hospitals require certification by the ABR and state licensure bodies to maintain staff privileges. And individual practices often stipulate that you need MOC to remain in practice.

But, you may hear about other specialty physicians in the news who have not renewed their certification. Many of these folks are leading political and internal movements to eliminate the MOC requirements. Individuals and organizations are suing certification boards who are teaming up with insurance companies and hospitals. Some of these boards aim to make MOC a requirement for radiologists to get reimbursed for the interpretation of images. Usually, the physicians not participating in MOC have been practicing for a while, so they have the clout to abandon the MOC process.

When Do I Need To Start With The MOC Process?

Over time, the ABR requirements about when to start MOC have changed. The MOC process begins on day one since the ABR now considers MOC to be continuous. According to the ABR, you need 75 CME credits over three years of practice to maintain certification. That means you could theoretically begin CME on the first day of practice or wait a bit to start.

On the other hand, each state has different requirements for when to begin MOC. You should look up your state online to determine which rules are correct. Again, refer to the site called mycme.com, which outlines the specific requirements for each state. For the state of New Jersey (my state of practice), they give you a grace period of two years to begin CME after the first renewal of your state licensure.

Former Actions Against MOC

According to a Medscape article from 2017 (1), many state organizations have been banding together to prevent the overreach of MOC. This article documents many of the individual state medical society activities. I thought these activities were particularly fascinating.

To summarize some of the activities in this article, multiple state medical societies have attempted to pass anti-MOC bills in their states. Most of these attempts are in process or have been temporarily tabled. One state, Georgia, became the only state to pass a bill that prevents using MOC as a condition of licensure, employment, reimbursement, or malpractice insurance at certain hospitals.

At the time of the writing of the Medscape article, several states have initially failed in their attempts to pass MOC legislation. Three state medical societies (Arizona, Kentucky, and Michigan) created stipulations stating state medical boards “may not require a specialty certification or maintenance of a specialty certification as a condition of licensure.” However, legislatures did not pass the bills. Oklahoma became the first state to attempt to enact legislation to remove MOC as a requirement for physicians to obtain a license, get hired and paid, or secure hospital admitting privileges. However, at the last minute, the bill failed after significant lobbying by ABMS (American Board of Medical Specialties).

Other state medical associations are in the throes of creating anti-MOC bills. Both Tennessee and the Florida Medical Associations aimed to create bills to defeat efforts by the ABMS and FSMB to impose MOC as conditions for reimbursements and licensure. Finally, numerous other states, including Maryland, Missouri, North Carolina, Texas, Alaska, California, Maine, Massachusetts, New York, and Rhode Island, are trying to enact anti-MOC bills.

More Recent Defeat Against The Anti-MOC Movement

Most recently, in 2021, the federal court of appeals affirmed the dismissal of physicians’ claims against the American Board of Internal Medicine claims that challenged the MOC process. However, other litigation is still ongoing. 

Summary

Regardless of your stance on MOC, it is integral to most radiologists’ practice. It will be present in some form or another for a long time, perhaps in a more weakened state. Follow the current rules when starting, and you will get to practice radiology. Be a revolutionary against the system, and you may have difficulties. Either way, the final decision is up to you!!!

(1) Chesanow, N (6/21/2017) The War Over MOC Heats Up. Retrieved from http://www.medscape.com/viewarticle/881274

(2) Reese, N. (8/3/2016) MOC Exam: Take It Or Not? Retrieved from http://www.medscape.com/viewarticle/864922

 

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Radiology Call- A Rite of Passage

call

Every year around the beginning of July, I see some of the most haunted radiology resident faces, right around 10:00 pm, just after the attending evening shift ends and the resident night shift begins. It is almost always a second-year radiology resident who happens to be starting their first night of call. What if I miss something important? What if I say something stupid? Will I be able to handle the intensity? Will I fall asleep? And most importantly, will I kill someone?

The resident only unlocks the answers to these burning questions on the first night. Only after this event does the resident and the program director know whether or not they can handle the burdens of a radiologist. Everything in the first year leads to this point: the precall quiz, the intense reading, the conferences, and the studying. It’s crunch time.

Just before the first night of the dreaded call, my famous last words are: you begin the night as a kid, and you will end the night as an adult. Why do I say that? Because I think the truth lies embedded in that statement. You can never become a full-fledged radiologist until you are responsible for independently making patient decisions. It’s like all those ancient traditions in all religions/cultures, like hunting that first wild boar, the confirmation, the bar mitzvah, etc. The residency now allows you to function as an independent, freethinking human being who can make decisions on your own. Until then, you are merely an observer, not an active participant.

Since taking night coverage is such an intense and essential experience, you must follow certain tenets to make it valuable and safe. I will enumerate eight simple golden rules of call I wish I had known before beginning those fated first nights to come. I urge that you follow all of them to enrich your education safely. Do not stir the wrath of your fellow staff members and program directors in the morning by breaching these rules!

Look at every film with these primary thoughts- what will kill the patient, and what is common?

I can guarantee that if you look at every film with these thoughts at the forefront of your brain and have done the prerequisite work to get to call, you will not severely harm any of your patients. When you look at a chest film, always think pneumothorax. If you see a female pelvic ultrasound, always think ruptured ectopic. When you look at a CT scan in a patient with right lower quadrant pain, always think of acute appendicitis. And so forth. Thinking about badness will prevent undiscovered horribleness in the morning.

Likewise, when you look at films, always think about the most common diagnoses first, and you will be right much more often than wrong. For instance: Opacity on a chest film- pneumonia, not Hampton’s hump. Restricted diffusion on a brain MRI- infarct, not ependymoma. Abnormality on a GI bleeding scan, think primary GI bleed, not Meckel’s diverticulum with bleeding gastric remnant. I can guarantee your attending faculty will look at you funny if you come up with too many zebras!

Always, always, always maintain your search pattern in every study.

In the radiology world, one of the main ways to miss something is not to look for it. Sometimes in the middle of the night, the pressure will seem impossible, and you must deliver an answer at that second. Perhaps, a team of 4 angry surgeons comes down and asks, “What is going on with the film?” and needs to know now! Or, an inpatient resident shoves a chest film in front of your face and says, “What’s going on here?” Maybe, the emergency medicine doctor calls incessantly to get a read on that CT chest for dissection.

In each of these cases, I don’t care how emergent and immediate they need the answer, always step back and go through your search pattern. Everyone makes this cardinal error at one time or another. Avoid it! Step back and say give me a moment. Go through each organ or region rigorously. You will look much less stupid than blurting a diagnosis/finding out only later to realize it was wrong because you haven’t thoroughly analyzed the study. One of the worst feelings is finding the doctor who just left your department with the wrong answer, who is getting ready to begin an unnecessary surgery on a patient, or a doctor who will discharge a patient that needs to stay in the hospital!!

If there is no harm to the patient, it is easier to do the study than to fight it.

Most residents take a while to learn this one piece of sage advice. At nighttime, you will have limited time for everything. Interruptions will pull you in fourteen different directions at once. You will receive calls from the emergency department, the floors, the surgeons, etc. And often, these events tend to happen all at once. So, I urge you that if a study is reasonable, do it.

You will spend more time and energy preventing a study from getting done than just completing it. Of course, if it significantly harms a patient, then obviously avoid it. But that is the exception rather than the rule. That fluoroscopy study to rule out a foreign body that you try to block after the resident ordered it: I can guarantee it will come back hours later when you are either exhausted or have lots of things going on at once. So, just do the study!!!

Don’t let your temper get the best of you. You will hear about it in the morning!

Every resident encounters a curt gynecologist, a rude surgeon, a loud, demanding resident, and so on at some point. You are likely going to be grumpy and tired as well. It may seem like a good idea to talk back to that person similarly rudely and unprofessionally. Or, you may want to take a swing at one of these annoying chaps. But don’t do it. One of the most common complaints at nighttime is a letter written by an attending or a resident colleague saying this radiology resident was unprofessional and handled the situation poorly under pressure. This complaint will come regardless of whether the radiology resident is right or wrong. And often, it will stay in the resident’s file/record. Don’t let that be you!!!

Residents best handle resident matters. Attending matters are best handled by attendings.

At nighttime, many times, a clinician may need an attending radiologist. So, make sure you don’t go in over your head. Call your attending when necessary. The worst thing you can do in the morning is to perform a procedure that your attending should have done or make a phone call that really should have been handled by your attending, only to find out that the wrong thing happened. It will become the talk of the town in the department, not in a good way. An attending should always read a brain scan because of litigation issues. A faculty radiologist should always be present for an intussusception reduction. And so on. Don’t go over your head!

On the other hand, if you have a resident issue at nighttime, try to handle it yourself. If the Emergency Department asks you whether to give the contrast, make that decision. If a resident comes down to ask a question, answer it. You will only learn how to make the more minor decisions by playing the role of a radiology resident.

Ask for help if you can’t handle something at nighttime.

Sometimes, the job may be too much to bear for one person. (A disaster happened with every patient getting a total body CT scan) Perhaps, it is a question that an expert needs to answer. (A subtle abnormality on an emergent Neuro CTA) And, other times, administrative issues that only your chair or program director can handle. (The MRI broke – should we recommend sending patients to another hospital?) If such problems arise at nighttime, make sure to call the appropriate channels going from lowest to highest in command. If it is a patient question that you are not sure about, ask your chief resident. Then, if they can’t answer the question, you may want to ask the assigned attending on-call. And, up the chain, it goes.

If you decide to handle everything yourself and it is inappropriate for your level, you can almost be sure that repercussions will occur in the morning. So please, ask for help when it is needed and appropriate!!

Always answer your beeper/phone/pager.

Occasionally, we hear about a resident sleeping and not answering their pager at nighttime. Unfortunately, those residents will often get written up in the morning for lack of timely dictation. So, jack up the sound on your beeper/phone/pager. And, take all calls!!!

Look at the films. Don’t rely on the ER or Nighthawk reads.

Being on call is the time to remove the umbilical cord and develop independence from your mentors/attendings. So, do not repeat a dictation or reading that is already present. You should do everything de novo/from scratch, although you should look at their reads afterward. It also seems silly when the resident’s dictation matches the Nighthawk dictation verbatim and hints that the resident may not have looked at the films. When I am on in the morning, I appreciate the extra set of eyes that a resident used to check the cases even though others have looked at the study. And, it is not infrequent that our residents catch essential findings that the nighthawk didn’t notice. So please, do your independent reads/dictations!!!

Summary statement

Call is a challenging but integral part of raising a radiology resident right. It is a time of trials and tribulations. You can and will make it through this harrowing trial if you follow the golden rules. Good luck!

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Need some help with what you need to learn before taking call? Check out the following books on Amazon!

Emergency Radiology Case Review Series

Core Radiology

 

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