Tag: research

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How To Keep Up The Momentum For Residency?

momentum

 

Question About Maintaining Momentum For Residency

Hi Dr. Julius,

I’m a first-year DO, and I am just finishing up the final exams for the first term. I’ve done very well so far and am on track to be near the top of the class, if not first (Though it is just the first term, much can change). I’ve had a strong interest in radiology before medical school, much of it due to my physics background as an undergrad.

I wanted to ask, how can I keep the ball rolling to make for a successful radiology application? I’ve heard conflicting answers about research. Some say that research isn’t as important in the eyes of PDs, but most of that advice I hear is towards MD candidates and may not necessarily apply to me.

I have two publications from undergraduate in my specialty field of physics. Still, I am a little lost on finding opportunities in radiology research, given that my school does not have a radiology department. Is it unprofessional to reach out to nearby departments to see if residents have any ongoing projects?

The Momentum Chaser

Answer About Maintaining The Momentum:

Hi Momentum Chaser,

I’m glad to hear that you are starting your medical school on the right foot. However, remember that the first couple of years are very different from your school’s clinical portion. Many students who do well during the first two years do not repeat the same grades when they make it to the clinical years when the medical school evaluates you on some of your softer skills. (Although some do) So, try to play nice in the sandbox to keep the momentum when you get to your clinical years!

Importance Of Research For Residency

Regarding research, the importance of it to residency programs differs widely depending on where you apply. And, I don’t believe it changes anything if you are DO or an MD. Some highly academic programs rely on their residents performing research during the four-year residency program. So, a Mass General type of program is going to want to see lots of research. On the other hand, a community program will not care to the same extent about the research you have conducted already. They will worry a lot more about having a good quality clinical resident. Specifically, they want one that can handle the overnight call and the residency workload. So, the answer to your question about the importance of research is it depends.

What To Do If Your School Doesn’t Have Radiology Research Opportunities

To answer your last question, it is certainly appropriate to ask other departments within your school or other sites for ongoing research opportunities. You may also want to consider finding a project within your school that may overlap with radiology, although not radiology specific. For example, there may be an internal medicine project that requires some imaging. I mention this because it can be more challenging to find projects outside your institution (although possible). To also answer your question, it is also professional and appropriate to ask about projects in nearby departments. It may be helpful to continue the momentum for your application and career!

I hope that helps a bit,

Barry Julius, MD

 

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Danger Of Using Case Studies To Dictate Imaging Policy: The Initial Covid-19 Study

case studies

Rumors abounded at the beginning of March 2020 about Covid-19. And, no one quite knew how Covid-19 would play out. All sorts of physicians were on edge to try to figure out what to do. But then a new case study about the role of CT scan arrived at the scene. And, clinicians began to read or hear about this “seminal paper” in Radiology that came out from China, called Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. This paper claimed a high sensitivity for the detection of the diagnosis coronavirus compared to PCR. Admitting physicians quoted it and demanded to get CT scans on their patients with presumed Covid-19. ER doctors were ordering Chest CT scans left and right.

What happened next? The throughput of patients slowed down to a crawl because the CT scanner needed special cleaning for potential Covid-19 contamination. Subsequently, this thorough cleaning delayed the treatment of patients. And, the CT scanner was out of commission for other patients that needed the CT scan for emergency workups.

Was it the right to use this paper to dictate the workup of patients? In hindsight, no. And, it brings up an all too common issue, the usage of case studies to dictate health care policy. So, what are the other factors that we need to evaluate before we decide to take a paper and apply it to patient care? Well, I will use this incident as a way to show you what you need to think about before using case studies to guide patient imaging. Let’s divide it into the following categories: practicality, throughput, exposure, and change in management.

Practicality- It’s Not All About Sensitivity Or Specificity

I don’t know about you. But, whenever I hear a test is highly sensitive or specific for a disease entity, I get excited. My first thought is usually, maybe we can use this exam to diagnosis patients? However, before arriving at that conclusion, we need to take a step back. Does the test make sense in the context of patients coming into the emergency department? Many clinicians did not think about these issues when they decided to utilize a CT scan to image presumptive Covid-19 patients. Just because you can make a diagnosis does not mean that you should complete a test.

Throughput is Important

A test is only useful when it can rapidly diagnose patients. In the case of CT scans for the diagnosis of Covid-19 patients, regardless of any other factor, our throughput for patient care significantly slowed down. And, this had a dramatic effect upon the patients that came into the Emergency Department for many other reasons. Always, physicians need to take this factor into account before jumping into ordering a test.

Exposure To Health Care Workers And Patients

We need to take care of all the folks that are providing services for the sick and infirm. If we do not perform this duty, we will have no health care workers to treat patients. In this situation, deep cleaning the CT scanner after each patient added undue risk to the technologists and nurses that completed these functions. Not to mention, you are also increasing the possibility of exposure to the next patient in the CT scanner. The upshot was a tremendous cost to the patients and employees.

Does It Change Management?

And, then finally, the most critical question that we need to ask ourselves is how does the test change management? In the case of Covid-19, a negative test did not preclude the possibility of the disease. So, regardless of the test outcome, the clinicians would need to use their clinical intuition to decide if they need to ventilate the patient or other invasive measures. Moreover, the treatment of the patient would remain the same, whether the CT was positive or negative. Why submit a patient to such a test?

Beware The Dangers of Using Small Case Studies To Dictate Policy!

We all need to take a step back when we hear the claims of physicians that we should be imaging a patient based on a paper. Instead, you should be answering the following questions: Is it practical? Will it prevent other patients from receiving appropriate testing? Will it endanger my staff and patients? And, does it change the management of the patient’s case? If the case studies can pass these tests, consider using it as a tool. If not, beware of imaging the patient based on a paper, the test may do more harm than good!

 

 

 

 

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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.

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Tackling Research- Basic Issues and Considerations for the Radiology Resident

research

Put an academic radiologist and a general community radiologist in the same room and start a conversation on research and radiology residency. How do you think that conversation would go? I bet there would be bitter debate and sharp words. It would likely be next to impossible to get them both to agree on the merits of radiology research.

The academic radiologist would point out the necessity of research to allow the resident to understand how to delve deeply into an area within radiology, understand the mechanics of making discoveries, and create and advance new areas of knowledge within our specialty. He would espouse the importance of statistically analyzing false positive and negative rates, ROC curves, sensitivities, and specificities, tools invaluable to becoming a good radiologist. Additionally, they would also likely say that without an understanding of the mechanics of the research process, companies can easily mislead you by marketing headlines for new software, contrast agents, radiology hardware, etc., that may, at best, marginally display the truth of an imaging process or at worst can be entirely incorrect.

On the other hand, the community radiologist would say that if you understand the fundamentals, can read films well, and know how to manage patients appropriately, what is the point of doing research? Let others develop new ways of interpreting films, creating protocols, or creating new contrast agents. Or in other words, “leave the research to the academics.” The community radiologist would also utter in the same breath that research is too time-consuming, costly, and incompatible with the day-to-day running of a revenue-generating practice. Why bother?

To What Extent Should You Pursue A Project?

So, given these diametrically opposite points of view, the big question becomes: to what extent should the radiology resident pursue research during residency? Should you make it into an all-consuming process or relegate research to satisfying your residency program’s requirements? Given the potential difficulties of making this decision for some residents, I will go through how to figure out for yourself whether you should follow the advice of the academic or community radiologist. In addition, if you go down the research pathway, I will give some sage advice about how to find a research mentor and what makes the best research projects.

How Much Research Should I Pursue?

Maslow’s Hierarchy of Needs

Ever read about Maslow’s Hierarchy of Needs? If not, I highly recommend you click on the previous Wikipedia link. Instead of Maslow’s Hierarchy of Needs, now picture the Radiology Residency Hierarchy of Needs. You might have to dictate films, study radiology material, and attend lectures at the base. At the apex, you would have radiology research. This point is so important: your own basic needs of a radiology residency must be satisfied before you tackle the research requirement. Therefore, you must answer some questions before starting a research project: Have you been studying enough, attending lectures, and learning the basics of radiology concepts? Are you performing well on your rotations? Do you have to concentrate on other issues, such as the USMLE? In other words, the resident must first focus on becoming a good radiologist and then their research. 

The entire pyramid will collapse without the essential elements of good radiology residency preparation. Why do I make this statement? Suppose the resident concentrates so heavily on research instead of learning all the imaging modalities and vital skills during their residency program. In that case, they will find it very difficult to perform well during residency. You want to ensure that you know the general skills of the radiologist first and foremost. Furthermore, too much emphasis on research can lead the resident to lose focus on other issues, such as passing the core examination. So, make sure not to forget about the main reason you are doing your residency: to become a radiologist.

The Rewards

On the other hand, if you can dedicate time to research because you can comfortably divide your time appropriately, by all means, go for it. The rewards are numerous from both a practical as well as academic standpoint. Significant research becomes essential if you are interested in academic radiology, love to come up with innovative ideas and enjoy writing publications. Publishing several papers and abstracts during residency and fellowship can help you get that first job if you want to pursue an academic career.

Even in private practice, performing research during your residency shows that you are interested in radiology. From a radiology job market perspective (although the community radiologist may not want to admit it!), if you have two equal candidates, one who has accomplished much research and the other who has done none, I believe most practices would choose to hire the former.

The bottom line- yes, research can be rewarding but make sure that it doesn’t interfere with your fundamental mission of becoming a radiologist!

How Do I Find A Research Mentor?

Most radiology programs have some attendings that are almost exclusively clinical and others that are more academic. I recommend you seek out mentors/attending with a decent amount of research experience. Although these clinical-based attendings can be great teachers and mentors for learning radiology, they will likely not be as valuable for understanding how to do research. They may express interest in helping you with research, but they cannot instruct you on completing a project. So, unless you have already had a lot of experience with radiology research, a more clinically based radiologist may not be the best choice for a radiology research mentor. There are a lot of radiology attendings out there that don’t have a clue how to structure a research project. (not that it makes them bad radiologists!)

Although not always possible, depending on the size and structure of your residency program, try to find a mentor in an area/subspecialty of radiology that interests you. It will more likely help you later in your career when you complete a project in your area of interest.

Finally, try to find a mentor that meshes with your personality. In addition to the grunt work of research, part of the research process involves bouncing ideas off one another and brainstorming. Exciting research can begin to seem more of a chore than a genuine passion if you feel you are not an equal participant. It shouldn’t be that way. Personality can become a significant issue.

What Makes The Best Projects?

My favorite research projects are those issues and problems that have constantly nagged at me or annoyed me over the years of practice that you have the itch to solve. In addition, I love research projects in an area of actual interest. These tend to be the best and most satisfying projects. I find that esoteric projects without relevance do not provide that spark to take the research to the next level. It also may dissuade the resident from pursuing other projects down the line.

I recommend that when you are involved in the day-to-day readouts, try to take notice of the issues that bother the attendings or questions that occur in the areas of interest you love. There are few things more satisfying than coming up with a question you thought about and then figuring out how to solve it.

Final Thoughts

Radiology research is an excellent avenue for understanding the mechanics of what we do as radiologists. We take many presumed facts for granted, whereas these facts may not be based on the best evidence available. Performing your projects allows the radiology resident to understand how to determine what information is genuinely facts and what information does not have a basis in science. This process helps the resident to read and interpret studies and critically define the accuracy of the information we use to analyze images daily.

Furthermore, delving into research by completing a project can be a very satisfying professional endeavor and become a capstone on top of our radiology residency training. Few things are more satisfying than answering your question, for which the body of literature did not provide an answer.

However, it is essential to remember that as a radiology resident, you must satisfy the basics of radiology residency first and foremost. Before deciding whether or not to become involved in a project, consider if you have the time and energy to pursue the project to its end. If a research project is very complicated and time-consuming, think twice about the project because your priority should be to become a well-trained radiologist. Radiology research can be rewarding, but only to the extent that you first satisfy the basic requirements of radiology residency training.