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How Should The ABR Test Communication Skills?

ABR

How should the ABR test communication skills? Isn’t that up to the residency programs? The ACGME maintains six core competencies. Only 1 of those 6 (medical knowledge) can be tested by board exams. Others, like professionalism and interpersonal/communication skills, cannot.

Anonymous Attending

 

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Great Question!

Testing Communication Skills

I believe testing and standardizing some basic communication skills before graduation is necessary. Currently, there is significant variability in the quality of communication teachings in different residencies. We certainly don’t want to create new graduates of residency programs who don’t feel comfortable relaying information expeditiously to clinicians or dictating a case. To that end, there are many ways that the ABR could test communication skills.

First, the resident may be able to answer questions in an appropriate dictation format to demonstrate they understand the mechanics of dictation. (At least that would ensure that graduating residents understand the basics.) Grading would be a bit more challenging, but there is no reason why the ABR cannot create such a scheme for a grading system. Second, the previous oral boards, albeit imperfect, did test residents’ ability to communicate the examination, the findings, the impression/differential, and management.

So, to say that ABR can’t test communication skills does not make sense. I’m sure we could develop a new and improved oral board type of examination to test the skill of communicating radiological findings to clinicians and patients in a much-improved way. Perhaps we could create a part 2 to the core examination. If the USMLE examination can do it, why can’t the ABR test for the same things but direct it toward the needs of radiologists?

Professionalism

I agree that testing professionalism is a more challenging nut to crack. Furthermore, unlike communication, professionalism is not a skill set but a way of acting ethically within the profession. You can’t standardize minimum requirements for professionalism in a test format. As you hinted, let’s leave that to the individual programs. But you can undoubtedly standardize essential minimum competencies for communication skills. And I think that should be the responsibility of the ABR if they want to establish the minimum abilities of a graduating radiology resident.

Final Thoughts

I believe we create excuses for ourselves to say it is impossible to test communication skills. It is certainly possible, and if other professions can do it, radiology can do it, too. To say that it is impossible or too hard is just pure laziness. It would just take time, rededication of funds, and getting together some intelligent radiologists and educators to figure it out. If called upon, I would be happy to give my input!!!

Director1

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Top 10 Common And Silly Mistakes Of Neophyte Radiology Residents

radiology residents

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

Uterus Vs. Prostate Gland

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

Hydronephrosis Vs. Obstruction

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

Calling A Kidney A Testicle

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

Overcalling Plain Film Artifacts As Radiology Residents

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

Not Doing A Rectal Exam Before A Barium Enema

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

Radiology Residents Calling Aortic Rupture Vs. Aneurysm Vs. Dissection

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

Calvarial Suture Vs. Fracture Confusion

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

Transverse Sinus Bleeds

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

Appendix Vs. Terminal Ileum Confusion For New Radiology Residents

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

Calling Flow Artifact Vs. SVC Thrombus

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

Establishing Credibility As Radiology Residents

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

 

 

 

 

 

 

 

 

 

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

barium

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

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

Direct Contact With Technology And Patients

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

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

Closer Contact With The Referring Physicians

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

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

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

Developing Radiological Hand-Eye Coordination

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

Managing And Learning About Radiation

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

Barium Work Is Not Sexy- But It Is Important!

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

 

 

 

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

credit card

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

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

Why Do Resident Physicians Need A Credit Card?

Laying out Money

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

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

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

Cash Back Credit Card

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

How To Establish Credit Without Breaking The Bank

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

Summary

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

 

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Buying vs Leasing A Car During Residency

leasing

Mass transportation is unavailable in all parts of the United States, unlike other countries, due to infrastructure issues and spread-out spaces. For this reason, many medical residents may consider buying or leasing a car during residency. It may not be such a simple question. Several times my residents have asked that I write a post on this subject matter. So, I will define what it means to lease a car and then explain how I would decide to buy versus lease a car with multiple thought experiments and comparisons.

What Is A Car Lease?

A car lease is a hybrid between buying and renting a car. It allows the lessor to spend a portion of the entire vehicle cost over a fixed period, usually with the option to buy the car at the end of the lease period at a depreciated amount. Monthly payments are typically less than a car purchase since it does not include the entire vehicle cost. The lease cost usually consists of the depreciating price of the car and monthly interest. The lease can contain additional fees in the monthly bill, including a charge for going over a fixed limit of miles and sometimes additional insurance costs not factored into a bought car.

The lessor will often put down a nominal fee at the beginning of the lease period. Bottom line- leasing a vehicle lets the lessee enjoy a more expensive car than they could typically afford with lower monthly payments. But the big question is- do they come at a significant cost?

Examples of Buying Vs. Leasing Cars

Whenever I make a financial decision, I like to take a mental picture of the different financial possibilities using thought experiments. Otherwise, it can be hard to understand the subtleties of the other arrangements. So, I am going to do just that with a typical car. I will assume the vehicle costs about 30000 dollars and that we will buy or lease the car over three years. Cars can be less costly if bought used, but for the point I am trying to make in this article, buying or leasing a new versus used car should not change the conclusions. In my first example, I will assume that we will hold the vehicle we purchased for over ten years and compare that to the costs of leasing for three years and buying out the lease after the three years are over. So, let’s do just that.

Scenario 1- Buying and Holding for 10 Years Vs. Leasing And Buying Out A Lease

Buying A Car

Let’s say the interest rates are 3% on the three-year loan for a new car and the lease. And, we will put down a nominal amount on the vehicle on both the car purchase and lease- say 2000 dollars on both. So, what are the monthly and total costs of buying a car over the entire period? To determine that, I will use one of my favorite financial programs in the world- a simple amortization calculator on the web from Bret Whissel called Amortization Calculator. So, the monthly payments on a bought car over three years after the nominal down payment is approximately 814 dollars for a total cost over the three-year loan of around 29313 dollars. The total cost of purchasing the vehicle will be 2000+29313 dollars or 31313 dollars.

Leasing A Car

How does this compare to the monthly payments on a three-year car lease? Let’s do the calculations. One of my favorite rules for determining the depreciation of a car that approximates reality is the rule of 10+9+8+7+6+5+4+3+2+1. For each year that you have owned the vehicle for up to 10 years, you can match the price of the car by taking the number of years that you have owned the vehicle, adding the numbers from highest to lowest for that period, and then dividing by the rule’s total (55). So, in this case, the amount of depreciation over three years would be 10+9+8/55 or 49%.

Alternatively, you can use a slightly more accurate calculator such as this one from Money-zine and develop a depreciation percentage of approximately 39%. For the sake of “accuracy,” we will use the more accurate calculator. The initial lump sum of 3-year monthly payments will be (0.39) (30000-2000) or 10920 without interest. Calculating interest at a 3% rate and using the amortization calculator, the monthly payments will be 317.57 dollars, and the total sum of payments over the three years will be 11433 dollars.

The Verdict

According to the calculations, the car’s residual value will now be 30000*(1-0.39) or 18300 dollars. Remember, the 2000 dollars you put down on the car does not contribute to the principal/cost basis of the vehicle. So, let’s finance the residual value payments over three years again at 3%. The monthly payments this second time around for buying the car out of the lease will be about 532 dollars, and the sum of the charges will be 19159 dollars. So, the total cost of the vehicle after leasing and then buying out the lease will be 2000+11433+19159 dollars for a total of 32592 dollars, not including additional leasing fees. The extra cost for leasing and buying out the car to get the lower payments vs. buying over three years is a mild difference of 32592-31313 or 1279 dollars total.

Scenario 2- Buying and Holding Vs. Continually Leasing for 10 Years

In the second example, I will compare leasing costs when you do not buy out the lease, continually leasing cars every three years over ten years, and compare that to buying and holding a car for ten years. So as in our first example, the initial cost of leasing the vehicle over three years will be 11433+2000 dollars. Let’s assume you will do that three and a third times over ten years. So, our total costs for leasing a car continually over the ten years would be 3.33*(11433+2000) or 44732 dollars.

For comparison, when we buy and hold a car for ten years, there will likely be increased repair costs for keeping a relatively older car. Let us then go ahead and add 500 dollars per year in repair costs after the initial three years of the loan for buying the vehicle. We will add that to the former loan price in the previous example or 31313+(7*500) or 34813 dollars. So, the additional cost for leasing a car continually over ten years compared to buying a car and holding for ten years would be 44732-34813 dollars or 9919 dollars, almost a third of the price of a car!!!

Scenario 3- Buying and Holding vs. Continually Leasing for 10 Years With Tax Deductions

In the third example, I will assume that the resident will moonlight and can deduct the car’s depreciated value from their total income annually at 25%. We will again compare the costs of releasing a vehicle every three years over ten years and compare that with buying and holding a car for ten years. Assuming you can deduct the depreciation from your salary, the new costs of leasing a vehicle would be [11433 (1-0.25) +2000]*3.33 or 35214 dollars over ten years. In this situation, the additional cost for continually leasing a car over ten years would be 35214- 34813 dollars or 401 dollars, which is more reasonable.

Scenario 4- Buying and Selling Over 10 Years vs. Continually Leasing Over 10 Years

In this example, I will compare what it would cost to buy and sell a new car every three years, assuming a 30000 dollar price tag for ten years without leasing vs. the cost of leasing cars over ten years. Most residents don’t like the hassle of constantly buying and selling cars, but it would be interesting to compare with leasing over the same time. So, let’s do the calculations.

Based on our initial scenario, buying the car every three years would cost 31313 dollars. So let’s assume we can sell the car every three years for 31313 dollars*(1-0.39) or the depreciated value of 19101 dollars. So, the cost over ten years would be 3.33*(31313-19100) for 40669 dollars. The additional cost for leasing cars over ten years vs. buying and selling cars over ten years would be 44732-40669 dollars or 4063 dollars, a moderate difference.

Scenario 5- Buying and Selling Over 10 Years vs. Continually Leasing Over 10 Years With Deductions

Finally, let’s compare the cost of leasing over ten years with the ability to deduct the depreciated lease value from your taxes compared to buying and selling cars every three years for ten years. The calculations were performed in several scenarios above, making these calculations easy. So, the total in this situation would be 35214 dollars for leasing and 40669 dollars for buying and selling over ten years. This scenario is one where it would be less costly to lease for a total savings of 40669-35214 dollars or 5455 dollars total.

What Can We Conclude Based on These Scenarios?

We have crunched all the numbers, and what can we conclude? The most stark difference under all these scenarios is between continually leasing a car for over ten years and buying and holding it for ten years. You would theoretically save 9919 dollars over ten years if you buy and own a vehicle, approximately 1/3 the car’s value. That’s a lot of money!!!

If you can deduct the car’s depreciated value from your income, then leasing a car every three years for ten years will be a slightly higher cost than holding on to a vehicle for ten years. If you like new cars, this proposition can make some sense.

Finally, the finances are almost always in favor of buying a car except for the one situation where you have to decide between leasing a car every three years for ten years and buying and selling a car every three years for ten years with the condition that you can deduct the depreciated lease value from your taxes because you are an independent practitioner/moonlighter/consultant. This situation would be highly unusual.

Final Thoughts

Always crunch the numbers based on your inputs (these may vary slightly from mine). But, for most residents, if you need a ride to work and must have a car- buy a car and avoid the lease. A lease will put you behind the eight ball over your initial working years, especially when getting rid of your student debt and beginning your savings/investments is crucial. On the other hand, if you can deduct the car’s depreciated value from other self-employment income, you can argue to lease instead of buy. And finally, if you are in the fortunate situation of being able to walk to work every day, perhaps you can do without a car altogether and save some money!!!

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How Far Should I Take That Procedure?

procedure

The Procedure Situation

Round 1

Your radiology attending tells you to interview a patient and then complete an ultrasound-guided breast biopsy, knowing that it was a large mass and a relatively simple case. You have done this procedure numerous times with this same faculty. So, you go ahead and do it again. No complications. No issues. After you complete the biopsy, you feel immense pride in your capabilities. You show the attending the pictures from the biopsy. The attending congratulates you on a job well done.

Round 2 later that same day…

A different radiology attending wants you to work up another patient and start the subsequent breast biopsy. So, you begin to interview the patient, set up the table and the sterile field, position the patient for the procedure, and place the ultrasound probe on the biopsy site. You begin to numb the overlying skin lidocaine and make a small incision for the biopsy gun. Since the attending still has not shown up, you decide to place the needle right near the lesion, hit the targeted breast nodule, and then subsequently collect multiple samples, placing each one into a little sterile cup on the side to send to pathology. You complete the rest of the procedure without complication. All seems to be well.

You clean up everything and let the patient know that everything went just fine. And, you tell her you are going to consult with the attending before you have her leave. So, you merrily step out of the room and walk down the hallway toward the radiologist’s office to let her know about the patient’s biopsy you completed. You enter the office and state, “I completed the biopsy successfully on patient “XYZ.” The attending stares at you with a stern, angry face and says, “How dare you complete the procedure without consulting with me!!!” You are the talk of the department for the next month!

How To Assess How Much You Can Do

Unfortunately, during radiology residency, you may encounter similar situations such as this one. Different attendings have entirely varying expectations for each radiology resident. Some may expect you to start and finish all procedures. Others may be less likely to allow the resident to have independence, even though he/she may be competent. So what to do? I will go through several guidelines in assessing whether you, as a radiology resident, should complete a given procedure on your own.

Are You Competent In The Procedure? 

Competency should be the first issue that you need to address as a radiology resident. Suppose you do not think you have done enough of a technique independently from start to finish. In that case, you certainly have no business doing any procedure or a portion of a procedure alone. The comfort level is also just as important. Even if you have the numbers of biopsies to back you up, if you do not feel comfortable with a procedure, you should also continue to make sure that you have your attending’s guidance at all times until you have that comfort level that you need.

Are We Doing the Procedure For The Right Reasons?

Before performing any procedure, you need to make sure that it has some clinical benefit. Nurses regularly come up to me and ask should we give intravenous contrast. The first thing I ask them is why are we doing the study/CT scan? It may not need contrast in the first place. Likewise, no matter how “minor” a procedure is, you always need to think about it if necessary first!!!

Level of Difficulty of Procedure/ Potential For Complications

Some procedures, such as an upper GI series, have a much lower complication rate than a complex liver embolization. So, it is essential to assess any given procedure’s difficulty and potential complications before deciding whether you should tackle it on your own. Most liver embolizations, stent placements, and angioplasties should probably be under the faculty’s direct supervision unless perhaps you are about to graduate from an IR fellowship in a few days. On the other hand, a paracentesis can undoubtedly be performed from start to finish by a resident.

Attending Expectations

Some attendings expect the resident to do almost everything and others feel the need to hold the resident’s hand at every step. Much of that decision may be related to the trust between the attending and resident. However, it is imperative to listen to the guidance of your attending before beginning or ending any procedure. Because you are not the physician who signs off on everything, you need to abide by the person’s rules in charge. Always make sure to get the OK from the supervising physician before performing any procedure!

Patient Expectations

Many patients expect an attending to complete a procedure. Always abide by the wishes of the patient. You never want to be caught in a situation where the patient does not want you to be performing a procedure, and you do so anyway. Not listening to the patient’s request is the realm of lawsuits and legal issues!!!

It’s All About Self-Awareness!

The difficulty of residency can be more about self-assessment/awareness and working with colleagues than about the actual day-to-day mechanics of performing cases. You, as a resident, need always to be aware of your strengths and weaknesses as well as your expectations. My advice: make sure to always know in advance that you are performing a procedure for the right reasons, have the abilities to conduct it, and your attending expects you to complete it. Only then should you consider performing a procedure independently!

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Radiology Residency Night Float Vs. Standard Call- A Perpetual Controversy!!!

night float

Blurry vision setting in; eyelids drooping just wanting to shut; difficulty communicating; and impending malaise. Rarely would I have any chance whatsoever to lay my head down even once. The films would keep on streaming in. These feelings were typical on that first night of call on a 1 or 2 weeknight float rotation block or the occasional Saturday overnight calls that we would have to do every once in a while. I dreaded those days. But, it is still standard for many radiology residency programs. It is almost impossible not to have at least a few overnight shifts like the ones I just described.

At one point or another, many radiology programs and residents have come up with different schedules and options to minimize this extreme fatigue. Some have instituted night float schedules. Others maintain a standard rotating call schedule Q4,5, or 6. Some have long and short call schedules.

The choice to do one system or another is not so clear-cut. Programs have many considerations before deciding to have either of these systems before implementation. Although I tend to favor the night float system since I remember it mitigated fatigue after the initial day or two of calls when taking overnights, the decision to have a night float program is probably unsuitable for all programs.

So what factors would lead one program to have a night float system and another to have a standard call system? Some of the issues we need to address are the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies, and emergency department requests. I will also review each system’s disadvantages and advantages, allowing a program to decide which approach is best.

Factors For Instituting A Night Float Coverage System

 

Size of the Program

The smaller the program is, the less likely there will be adequate coverage for rotations during the daytime, let alone the nighttime. In fact, at many programs, a small residency cohort prevents the institution of a night float system. In a program with three or fewer residents per year, it may not be possible to have a resident out every night to be on call without severely compromising resident education. Also, many programs cannot cover daytime obligations without a night float system.

Attending Coverage

Institutions with attending nighthawk coverage at nighttime allow more flexibility for scheduling of night float. Some programs do not need full-time resident coverage during the nights and may share call obligations with the attending. Therefore, it is significantly easier to institute a night float system for the residency program.

Resident Preferences/Culture

In some residencies, the radiology residents have instituted a night coverage system because of the preferences of the individual residents. Many residents have fully invested in a given scenario. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or fewer calls than they would have in the old system. So, the night coverage system becomes engrained into the fabric of the residency program.

Also, the program director may set up this schedule to accommodate specific residency daytime programs. A nighttime schedule may allow the resident to maximize daytime educational opportunities. For some programs, that may mean either a standard cyclical call schedule, and for other programs, it may mean a night float schedule.

Program Director/Chairman Preferences/Department Culture

In many programs, the leaders may institute nighttime coverage based on their preferences. The program director or chairperson may believe a night float system or standard call schedule may be better for a residency program. Or, perhaps there are coverage requirements that the department desires. In either case, the decision is not up to the residents.

Number of Studies

Perhaps you are in a residency program that is a level 1 trauma center with significant numbers of ER studies at night time. Some programs are so busy that they may need more than one resident or attending on-call each evening. This factor may allow less flexibility in scheduling a night float system since a program may not be able to accommodate the call coverage at nighttime.

Emergency Department Factors

Emergency departments may have specific requirements for radiology coverage at nighttime. Some programs may only want to have senior residents take call. Others specifically want attendings to cover during the evening. Depending upon the demands of the emergency department, this may dictate the numbers, type, and presence of residents or attendings on call. A night float system or standard call system may reflect the whims of the emergency department.

 

Advantages/Disadvantages of Night Float And Standard Call

Night float

Most people think night float coverage for a week or two mitigates fatigue the most. The body tends to get used to the nighttime schedule over time, allowing the resident to function better on call. Sure, the first few days can be challenging because the body and mind have to adjust. But overall, the experience is much improved.

On the other hand, when you are on a night float system, the resident may lose touch with the “educational” aspects of the residency program. You miss daytime lectures, conferences, and attending readouts for long periods. While the time spent on night float is essential for training, receiving all the benefits of daytime resident education is impossible. You may lose out on understanding the context of the images you interpret. Education, in this sense, may also be compromised.

Standard Call

Sometimes a Q4, 5, or 6-day call schedule integrates better with a program than a night float system, allowing the resident a better overall experience. The resident does not miss all the noon conferences and educational experiences they would miss over a long block on a night float.

The two significant disadvantages to the cyclical call schedule are overnight fatigue and the “lost day.” As I mentioned, I always found it much more taxing to have an occasional overnight than a night float block because my body never adjusted to the system, just like most residents. In addition, the resident loses an extra day of residency experience every time they work because they are obligated to have a day off afterward, “the post-call day.” This loss can significantly decrease the educational opportunities for the resident.

 

Residency Call- Night Float or Overnight Calls?

Nighttime call is a crucial facet of every radiologist’s education. Whether or not you have a say in constructing your program’s night coverage system, you now realize that what works for one program may not work for yours. The decision to have one or another method can be complex, but it is important to weigh each of the factors to come up with an outcome. The key is to make the learning opportunity pleasant and mitigate fatigue. Hopefully, your residency has chosen your institution’s most appropriate night coverage system!

 

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I’m a sick radiologist- Should I come to work?

I am confident that most of you, whether a radiology resident or an attending, have felt sick at one time or another. And, most likely, you were unsure about coming to work. Moreover, this decision can become incredibly complex.

Here are some of the issues you probably thought about. Is there adequate coverage? How sick are you? Are you going to be seeing patients for that day? Are you going to be sitting down in isolation for most of the day? Are your reads or your procedures going to be compromised by your illness? What is the group’s culture about taking a sick day? How will it affect your colleagues if you do not show up? Will it prevent you from being promoted? Unfortunately, these difficult questions compound when you cannot think clearly due to illness.

Even more confusing, most of the articles that I have read regarding physicians and sickness are not written directly for the radiologist. Radiologists are a bit different than other hospital or outpatient physicians. Depending upon the day, the rotation, or job description we may or may not have direct patient contact. So, we have to have to think about the question of missing a day of work differently from other physicians.

What about the literature regarding sickness for the general physician? Many articles say not to come to work if you are a sick physician. (1,2) And others are more indeterminate. (3,4) However, the body of research is sparse about whether the ill physician, let alone a radiologist, should come to work. In this post,  I will try to address the most common issues that may sway your decision one way or the other.

Continue reading I’m a sick radiologist- Should I come to work?

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Hiring Radiology Physician Extenders- Helpful for Residents?

physician extenders

Many radiology practices throughout the country are understaffed and overworked. But, it is not just the attending radiologist that can suffer the consequences of decreased time and increasing workload; it is also the radiology resident. Due to the increased burdens of radiologists, radiology residents may have reduced time to attend conferences. They may also have increased service obligations and less availability to perform procedures. Overall, the psychological stresses of residents to complete the daily work increase every year. One potential solution for the hospital-based radiology practice to improve these conditions is to hire physician extenders. So, I will briefly discuss the types of physician extenders, how programs can utilize them in practice, and finally, how residencies can use physician extenders to improve the residency program.

Types of Physician Extenders

Multiple excellent articles describe the roles of physician extenders. Some of these articles include an Applied Radiology summary called Physician Extenders: Which one is right for you?. Another one is an ACR article called Registered Radiology Assistant/Radiologist Practitioner Assistant. And, then there is a sirweb report called: Position Statement: The Role of Physician Assistants in Interventional Radiology. I highly recommend reading these articles to get the nitty-gritty details of each type of radiology physician extender.

But to summarize, I am going to list the different types and describe each briefly. These include Physician Assistants, Nurse Practitioners, Radiology Practitioner Assistants, and Registered Radiology Assistants. According to the sirweb article, only Physician Assistants and Nurse Practitioners can “order tests, write prescriptions, make diagnoses, and get reimbursed for services performed.” On the other hand, all of these physician extenders, including the Radiology Practitioner Assistants and Registered Radiology Assistants, can perform procedures. So, for a practice that needs more than just procedural help, Radiology Practitioner Assistants and Registered Radiology Assistants may not fit the bill.

How Programs Utilize The Physician Extender?

As I have perused the literature and forums on this topic, I have found that the responsibilities of the Physician Extender to be pretty varied. (1) Most commonly, they tend to work with interventional radiology and help to perform procedures such as Paracentesis, Thoracentesis, and Catheter Placements. But, they can involve themselves in more complex procedures such as Nephrostomy tube placements.

In addition to procedures in many practices, they also take responsibility for preliminarily approving patients for cases, taking patient histories, and getting consents for procedures. And Nurse Practitioners and Physician Assistants can write orders before and after cases. Also, they can create preliminary dictations. In some academic practices, they can even help out with data collection in research studies. So, their practice responsibilities can be beneficial to many different types of educational environments.

Are Physician Extenders Helpful For Residencies?

Do not fear radiology residents. Physician extenders are not here to take over the world!!! For most radiology residencies, the ability of the physician extender to perform such varied work allows the radiology resident and staff to focus on other more critical needed learning issues. These physician extenders are independent but not independent enough to run a department for themselves, so they will never take over the radiologist’s job.

What Can They Do?

At the same time, imagine you are responsible for getting consent during the daytime for all the PICC lines, and for the first time, the practice has introduced a physician extender. Now you can share in the responsibility of obtaining consents. They can write notes on the floors and talk to family members. These activities will allow you and your attendings to concentrate on some of the more advanced work in the department.

In addition, some physician extenders have lots of procedure experience and are excellent teachers. You may have a physician extender who can teach you how to do a PICC line or Portacath when the attending is not directly available. Or, the physician extender can perform procedures such as paracenteses and allow the attending and the resident to take care of other more complicated cases simultaneously.

My Experiences

Although I am not an interventional radiologist, my experiences with physician extenders have also been highly positive. When I was a resident, the practice hired a nurse practitioner, and he helped organize what we called “tube rounds.” It was a time in the morning when we would decide if we needed to pull catheter tubes, keep them in, or recommend other interventions. I learned a lot from both the physician running the “tube rounds” and the nurse practitioner who became adept at taking great clinical histories and understood the patients he followed very well. He also became friendly with many of the clinicians, such as the surgeons and GI doctors. It was a net positive for the medical team and my learning experience. Also, I’m sure he brought in more business for the hospital as well.

Physician Extenders Can Be A Radiologist’s And Residency Program’s Best Friend

In today’s demanding environment, a physician extender can be the right fit for an academic department. The ability of the extender to do procedures, teach, and consult can be a significant benefit for the busy attendings on staff and the residents in the department. Not only can it increase department productivity, but it can significantly increase the morale of the attendings and residents alike. It is a decision that programs and hospitals need to weigh carefully. But for many departments and residency programs, the physician extender brings significant long-term benefits.

(1) J Allied Health. 2015 Winter;44(4):219-24. Radiology Physician Extenders: A Literature Review of the History and Current Roles of Physician Extenders in Medical Imaging.

Sanders VL1, Flanagan J.

 

 

 

 

 

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The Other Struggling Radiology Residents

struggling radiology residents

A radiology residency program is like a family. When one person is afflicted academically or professionally, all of its members suffer down the road. Just as important as it is to be aware of and help the struggling radiology resident, it is also important to remember that one struggling resident can have severe repercussions for the remainder of the radiology residency program. It is not just the program director and chairman that reap the consequences of the struggling resident. Often unfairly, the class members take up much of the additional burden. The result be extra call shifts, less time spent on educational rotations, uncomfortable personality conflicts, or spare time spent educating the failing resident. So, I am dedicating this post to the other radiology residents affected by the struggling radiology resident. First, we will explore how other residents can appropriately identify and help the struggling resident and possibly get this person to the program director’s attention. Then we will go through what a resident should and should not do when a resident is academically or professionally struggling. And finally, we will examine how the residency program should commit its resources toward the struggling resident vs. the other radiology residents.

 

Identification of Struggling Residents by Colleagues

Often, the first residency program members to notice that a resident is struggling are not the program director, chairman, or attendings. Instead, it may be the struggling resident’s colleagues. Fellow residents are more likely to interact with struggling residents socially in a more comfortable setting. Here, the struggling resident is more likely to discuss his/her issues. This interaction is an opportunity to learn more about your classmates’ feelings about residency. They may even ask for your help. My advice is to give your classmate whatever assistance is reasonable so they can perform well. Residency is not a competition; it is a team environment. In addition, the help you give your fellow struggling resident will return to you many times. Whether you decide to teach your colleague or help them out with other residency issues, you will find that you will learn more about your material and yourself. Even better, you may be able to stem a progressive downward spiral to probation. Or, even better, prevent your classmates from suffering more dire consequences.

How To Identify The Resident

Sometimes the identification of the struggling resident is a bit more subtle than a simple comment about their struggles. Unlike an attending that sees a resident on a noon conference or a single day, you, as a fellow resident, may notice a pattern of taking cases and missing all the findings each time or multiple absences not recorded by the program. Or you may see bad habits such as drinking too much, something a little bit off, or a strange affect. These signs can be essential sentinel events. And you may want to address the issue with your program faculty to ensure the struggling resident gets the help they need.

In the end, it pays to identify the struggling resident. Remember, it often affects not just that resident but the entire program.

How Can The Residents Help With The Academically Struggling Resident?

The program directors, attendings, and chairman are primarily responsible for handling the academically struggling radiology residents. But, for the struggling resident’s rehabilitation to succeed, the program often needs to have the participation of all. The role of the other residents can be the key to the stability of the program through this trying time as well as increasing the likelihood that the struggling resident will eventually succeed.

Before any remediation, it is critical to determine if the struggling resident is willing to accept the help of the other program members. So, the role of the other residents can only begin when the struggling resident asks for help from their colleagues. You certainly cannot force a struggling resident to participate in remediation efforts if the struggling resident is unwilling or able.

Interventions To Help Academically

If you remember the previous article- The Struggling Radiology Resident, we discussed how the academically struggling radiology resident might have difficulty coping with the quantity or quality of their work. So, I will briefly review how the other residents should attend to these issues.

What should their colleagues do for a struggling resident who cannot schedule an appropriate time for studying? This dilemma becomes a time management issue. It would be fair to help the struggling resident to create a schedule for themselves. Sometimes it helps to sit down with the struggling resident and show them how you schedule your study time and what you have been reading on each rotation.

For a struggling resident with difficulty with the quality of study time, it would make sense to have group study time and present cases to one another to improve their presentation when reviewing studies. Or, it may be a good idea to go over questions with all the residents to practice testing skills. These processes help the struggling resident and may be good practice for the team.

How Can The Residents Help With The Professionally Struggling Resident?

Regarding a professionally struggling resident, fellow residents must be more careful with assisting in interventions. The intervention will depend on the primary cause of professionalism problems.

The Absent Resident

For the resident that is often absent, it may be possible to address this issue by asking the resident where they have been or why they have not been around in a non-confrontational manner. Sometimes the struggling resident may not be aware of the burden they are placing on the other residents. This interaction may make this resident aware of the issues he is causing and take responsibility for his actions. Again, if this does not work, bringing the matter to the program’s attention may just be as essential.

The Personality Dilemma

You must be more careful with the resident with personality issues, whether an abusive or unengaged resident. If you are friendly with this resident, it may pay to find out the cause of the behavior. But be careful not to be overly intrusive, as getting involved much further may be inappropriate. Indeed, if the struggling resident is amenable to helpful suggestions for conflict resolution within the residency, talk to this person about some of these issues in an appropriate setting. Or, it may be relevant to suggest this resident seek professional help if the resident is amenable.

In many programs, some struggling residents will experience psychiatric issues just like the general population. Or, they may get involved with alcohol or illicit drug use. These situations can be extremely touchy. Many of these residents may not have insight into their problems. And, they are likelier to refuse help from colleagues or attendings. Of course, a few may have an understanding. But, if you notice a struggling resident with one of these issues, it is usually best to bring the issue to the attention of the program director or chairperson of the department so that they can get the resident into the appropriate channels for treatment. Of course, there are exceptions to every rule. And occasionally, the struggling resident’s colleagues may have intimate knowledge of the resident. Therefore, they may be more likely to be able to get the resident appropriate help. But, be careful in this situation because there can occasionally be unforeseen legal and professional ramifications to the caring colleague. A resident without insight into their problems may see this helpful resident as antagonistic and can theoretically pursue these channels.

How to Commit the Program’s Resources

Over my tenure as associate residency director, I have learned that dealing with struggling radiology residents’ issues can drain a program’s administration and resources. The time you usually spend toward improving the residency program instead needs to be placed on the problems of the one resident. Especially in smaller programs with less faculty and monetary resources, the extra time can overwhelm the program directors, chairperson, and heads of Graduate Medical Education. While the struggling resident must get the necessary help and remediation, we have to remember that other residents also need to have a functional residency program. It is easy to forget about the other residents in this process. So, it is the residency director and chairman’s role to place additional efforts to concentrate on not just the struggling resident but the other residents at these times and to ensure the residency program continues running smoothly.

Back To The Other Residents

Every program, at one time or another, will have struggling radiology residents. And fellow resident colleagues need to help out, if possible, with identifying and remedying the struggling resident. But, the other residents often suffer the most from the consequences of a struggling resident’s actions. And the residents can be hurt by the administration’s choices to help the struggling resident. So, everyone involved needs to make a concerted effort not to forget about the struggling resident’s colleagues. Or else, these residents can truly become the “other struggling residents.”