training Archives - RadsResident

Posted on September 25, 2022 by Barry Julius

Top Ten Signs You’re Not Ready For Call

Last week we discussed the Top Nine Signs You Are Ready To Take Call. So, I figured I would not do justice to the topic of being ready for call without also creating a list of those signs that you might not be ready to take radiology overnights. Therefore, I have dedicated this list to those that think they are ready but are not. Maybe this is you? Check it out if any of these signs apply to you!

Never Double Checks Anything (Anything Goes!)

Our words matter, and anything that you say, the ER can use against you later on. If you recommend another test, guess what? You will probably get that test the same night! So, the resident who never checks their dictations to make sure everything makes sense and is corrected is in a world of hurt.

Anger Management Issues

If you constantly fight with your fellow residents or, even worse, your faculty, you probably need to settle down a bit before taking overnights. Ready residents can control their anger and not take it out on others because they know what they are doing. If you are in the former category, think about why that is!

You Repeat The Nighthawk Dictation Verbatim

If you rely on the nighthawk dictation as a crutch, it probably means you are not ready to strike it out on your own. You should go through every case as if it is new, even if another radiologist has already dictated it. You never know what they are going to miss. And, you certainly don’t want to miss the same things!

Never Looks Up History/Priors/Call For More Information

If you think you know it all and don’t ever need additional history or the need for priors, you are in for a rude awakening. The number of findings that you miss will be incalculable. And, you will miss the point of your imaging studies more often! It is one surefire way to mess up your cases at nighttime!

Assumes The History Is Correct And Relies On It Explicitly

Using history as a crutch is an elementary mistake that can lead to disaster. I can’t tell you how often the ER calls for hepatobiliary scans to rule out cholecystitis, even though the patient doesn’t even have a gallbladder! We need to check and recheck our work and compare it to priors to ensure we are doing a good service for the patient!

Disorganization And Routinely Forget Cases

If you forget to read films or complete your work during the daytime, do you think you will remember to finish everything at nighttime? Disorganization can lead to disaster. You can wind up dictating the wrong case on the wrong patient if you don’t watch what you are doing. So, get yourself into shape before starting!

Cannot Get Through The Daytime Cases on Time

It’s not just accuracy that matters at nighttime. Speed is critical as well. And, if you cannot get through work during the daytime, what makes you think you will get through everything at night? Cases will often come in batches, and everyone needs a timely report when this situation happens. Make sure that you are up to the task!

Only Knows The Aunt Minnie Diagnoses And Never Scrolls Through Cases

There is a big difference between knowing the diagnosis based on a solitary image and having to make your finding on an entire case that has hundreds of pictures. If you think you can get through your studies without the experience of scrolling through lots of cases, you will have lots of problems when you have to make all the findings at night.

Unintelligible Dictations

Do your attendings always tell you to edit your dictations because they can’t understand what you are trying to say? Well, listen to these folks very carefully. Dictations are the final product of what radiologists do. And, if you cannot say something intelligible, you have no business being on call!

Lack Of Rigorous Search Patterns

Every resident needs a rigorous search pattern when they are working at nighttime. Lacking a search pattern is a recipe for missing all the critical findings. If you never look for the spleen, you will never know it is absent. And so on. Hone in on your search pattern skills before starting to take call!

Are You Not Ready For Call Yet?

If one or more of these signs describes you, you may not be ready to take your first call. However, there is still a bit of time. So, go ahead and make adjustments before it’s too late!

Posted on September 4, 2022September 4, 2022 by Barry Julius

What Is The Optimal Call Situation For Radiology Residents?

Almost every program has its method of giving radiology residents the “call” experience. But, by no means is it standardized. Some programs have in-house attendings to back up the residents. Others use nighthawk, some all the time, and others sparsely. Some don’t have much in-house backup at all. And others weigh CT scans more highly than other modalities. And the list of possibilities for any given program can vary on and on. So, what critical elements of the optimal call situation should you look for when you are thumbing through the different radiology programs out there to find the one that best fits you? Of course, I will give you my two cents!

Independence Of Decision Making For The Optimal Call Situation

First and foremost, unless you want to do research permanently and cannot give a lick about making independent decisions, you should consider this priority one when searching for a call experience. At some point during your residency, you must make your own decisions, which need to count. Without this factor, you will never truly leave your first year of residency. The ability to make sound decisions is the difference between a student and a radiologist. So, make sure you have the power to make some decisions in each of the different modalities. Each modality that you cannot make an independent decision for is one less modality your residency will prepare you for when you finish!

Meaningful Decisions To Have Some Affect On Patient Management

To be clear, making a decision is not enough. The decisions that you make need to have some impact on your workup. The pressure of worrying about patients will keep you up at night, both as a resident and as an attending. Making calls that go nowhere will not be enough to satisfy the requirement of independent call. Every radiologist needs to know the consequences of what we do. Otherwise, you will become powerless to make these same decisions in practice.

A Reasonable Quantity Of Cases

It is easily possible to veer on either side of this equation. Some residencies are so overburdened with cases that the resident has no time to think and make decisions. So, too many of the decisions are bad ones. Likewise, if you are working call at a podunk hospital that is about to close from a lack of patient visits each year, this is not such an optimal call situation for learning either. At nighttime, your residency should have enough work to teach you how to become a radiologist. It’s hard to give you an exact number, but it’s usually a little more than you might think!

A Good Mix Of Cases

Some institutions are in counties where everyone comes from the same culture/background. This mix of cases is not such a great recipe for learning about the diversity of radiology. Also, if the program relegates you to read CT only and gives you no opportunities to look at MRI and plain film cases, this situation will not serve you so well. Find a residency where you can get sufficient studies in all modalities and patients.

Nighthawk Vs. Q Night

Finally, I have always been a proponent of the nighthawk system. I believe it will make your residency life a whole lot better for most of you. I find it very hard to adjust my sleep schedule to the every 4th-day rhythm. On the other hand, your body will get used to the nighthawk sequence reasonably quickly so that you no longer have the 4:30 am blues when you cannot see straight. This factor may not matter much for some with different circadian rhythms. But for me, it makes a humongous difference!

The Optimal Call Situation For Radiology Residents

No call situation is perfect. However, to optimize your overnight learning during your radiology residency, find programs where you have independence and meaning in your decisions, a decent number and mix of cases, and a nighthawk rotation. You will discover that these features will enhance your learning once you practice more independently, which will eventually spill over to your work as an attending. At that point, you will feel comfortable in your skin, knowing that you had excellent training!

Posted on August 8, 2021June 9, 2024 by Barry Julius

How To Overcome Imposter Syndrome As A Radiologist!

It’s the beginning of the new academic year. Many of you have just started your journey in the radiology world. Others are beginning their first foray into fellowship or as an attending. In each of these situations, you will likely start to doubt yourself. In the case of a first-year resident, other physicians will ask you questions that you believe they know more about than you do. As a fellow, you are probably unfamiliar with all the subtleties in your “expertise.” And, as a new attending, it will be hard to believe that your name will go at the bottom of the report, possibly alone. How can you handle all this responsibility? Are you even worthy? In each of these situations, you are undergoing imposter syndrome. You feel like you don’t have the knowledge and confidence to play your role in the healthcare system. So, what do you do?

Solutions To Imposter Syndrome

Act The Role

Now, I don’t want you to get in trouble. Of course, don’t say things that can negatively affect patient care, especially if you don’t know a topic that can affect a patient’s morbidity or mortality. However, if a resident or attending stops by to look at a film, don’t hesitate to say yes. Go through the case. Look at the priors and the report. When you look at cases with other staff, you develop more confidence in your consulting role.

Additionally, make yourself available for all procedures. Each time you perform the subsequent barium study, PICC line, or paracentesis, your hands and brain become slightly more familiar with the technique. This process allows you to feel more comfortable in your skin. Eventually, you will feel like you know what you are doing!

Becoming good at a role involves becoming a good actor at first. Eventually, the acting job will turn into your career, assuming you put in the work. And you will feel like you know what you are doing!

Read A Lot

As you probably know, radiology involves much more reading than most other specialties. This burden is due to our overlap with many specialties and the core examination. If you are not reading, you sure will feel like an imposter. At a conference, everything sounds like mumbo jumbo chicken gumbo. With the clinicians, you will be at a loss. But that all changes once you start reading intently. I promise. Whether reading films or other complicated radiology tasks, you can answer questions and feel comfortable in your skin.

Get Involved Actively In Your Specialty

Those who know many others in their career will rarely feel like an imposter. If you know all the “muckity mucks” locally, regionally, or nationally; you will feel much more grounded and connected to the world of radiology. So consider heading out there and meeting and networking at the RSNA, AUR, ARRS, and more. (especially when the pandemic eventually subsides!) Or, get involved in your hospital administration by participating in conferences, GME, or other resident administrative roles. Each time you do so, you will feel more invested in radiology and less likely to catch imposter syndrome.

Imposter Syndrome And Radiology: You Can Overcome It!

Only a few simple steps can move you down the road from imposter to maven. Acting the role, reading, and actively getting involved in your specialty are simple ways to move in that direction. Most of us feel like an imposter from the get-go. We have never done anything quite like radiology before starting our radiology track. But you can leave that position quickly. It’s a bit of work to end imposter syndrome. So, get cracking!

Posted on July 11, 2021April 28, 2024 by Barry Julius

My Experience With The Powerscribe Undo Button: A Call For Better Technical Radiologist Training!

I find one button on Powerscribe more satisfying than almost any other. No, it’s not the sign button, although signing off a study feels quite rewarding. Indeed, it’s not the auto text button. However, I press that one all the time to make my templates. And it does shorten my dictation time. Instead, it is that button typically buried in the edit menu of Powerscribe, the lowly undo button. I can’t tell you how many times I clicked the wrong button to lose half my dictation. And then I clicked on the Undo button to restore it to how it was.

Most of you are aware of this undo function. It returns anything you did before to its previous state as long as it was a line of spoken text, a cut, or a paste. But imagine not knowing about its existence. Well, that was my world as an attending physician for a good year or two. Now, it is embarrassing to release this information to the masses. But I have to let it out. It is true. I spent eons trying to recreate what I had dictated before without knowing there was a simple way to retrieve the information. I was not aware of the existence of the undo button for way too long. Imagine that.

The Undo Button: A Symptom Of A Bigger Problem With Radiology And Technology

This point about the undo button brings me to one of the most significant technical radiology issues. We, as radiologists, don’t know about so many computer and technology functions that can potentially make our lives easier and shorten our days. Now, maybe this issue is somewhat magnified because I have reached middle age, but I don’t think that is the case.

I have seen younger physicians, like residents and early attendings, who need to learn how to link two studies together and compare them slice by slice. I have seen other attendings needing to be made aware of the simple functions of our software for calcium scoring, which would have saved them tons of time. And there are many other time-saving technology tools I am unaware of. If all the radiologists were to pool their technology know-how together, we would all shave off an extra hour of work every day. So, why do we not receive the technical training we need to make us more efficient at our job?

Radiologists Do Not Receive Formal Training Because We Are Expected To Learn On Our Own

Many radiologists jump headfirst into the world of dictation and PACS without receiving any formal training. Many of you who work for hospitals and imaging centers know what I am talking about. As a resident, I cannot remember any technology folks training the residents on using PACS. That same philosophy has continued throughout the years. Hospitals and imaging centers expect us to use our highly paid professional time to figure it all out independently.

Technology Trainers Don’t Know How To Train Radiologists

Several things happen when we get the “training” we need from the technology folks. First, they show you what you can do and allow you to play around with everything. And then they say you need to use it for a while to get accustomed to it. While that is undoubtedly true, we often miss out on multiple functions and knowledge that can increase our efficiency. The problem is that the technology experts training you are not radiologists. And they will never know the most important functions we need to use.

Lack Of Time/Money Dedicated Toward Training

Or, once in a while, you will get an excellent technology expert who will try to help you by creating hanging protocols, setting easy keys, and more. Some may become irritated when they realize they need to sit down with you for an extended period to make the technology precisely how you like. Or, the institution received a package deal that included limited training for the radiologists. The bottom line is that you may receive less education than you need.

Learning The Undo Button: A Simple Solution To Improve Workplace Efficiency

So, why do I bring up an entire blog about a simple undo button and the issues that go along with it? Well, it is a cry for good, down-to-earth technology instruction that every radiologist should have. We, as radiologists, hear about burnout and misery all the time. But, it is the little things that make radiologists happy. Radiologists are highly paid professionals who should become as efficient as possible to save time and money. Many excellent radiologists have left the field because of simple technology inefficiencies such as this one. Coming home 20 minutes earlier every day to be with our families should be a much bigger priority for radiology practices and hospitals. Improving radiologists’ technical and computer training is a simple and relatively inexpensive fix.

Posted on November 22, 2020 by Barry Julius

How To Be Successful In MSK Imaging

We’ve been through the first two parts of the how to be successful series, nuclear medicine, and breast imaging. Part three, today, is all about how to be successful in MSK imaging. Like the previous weeks, I will talk a bit about the reading materials for this rotation and discuss when you should learn what. All the text links to books in this summary will lead you to Amazon, where I am an affiliate. Afterward, I will give you some more final thoughts about MSK imaging in general and how you can succeed in this rotation.

MSK Reading

MSK reading is a bit more varied than some of the other rotations and more decentralized. Different books are better than others for various topics. Because you need several different books on this rotation, it can be a bit more expensive. If you can try to borrow some of the books, you can save a bit of money. But if you decide to purchase them, they are good references to have nonetheless. Either way, using multiple books on this rotation will be much more efficient for studying MSK than using just one because no one book is comprehensive and intelligible enough for both the core examination and real-world practice.

In the following sections, I will divide what you need to read by each year of MSK. We will cover the following topics: trauma MSK, arthritis, musculoskeletal MRI, bone tumors, and other miscellaneous topics like musculoskeletal ultrasound.

First Year

First, you need to learn bone and joint plain film anatomy. So, in the beginning, especially, you will want to know about normal anatomy to get a better sense of how the different sorts of fractures look. If you are a first-year resident, review your anatomy books again from medical school (i.e., Netter’s or a cross-sectional atlas like Cross Sectional anatomy CT & MRI). You will then want to start with a book of the basics about common types of fractures, especially in an emergency setting. One of the resident-recommended books for this stage as a first-year resident would be the Fundamentals Of Skeletal Radiology. I used something similar many years ago. This book gives you some of the essentials of what you will need to know.

First Or Second Year

After knowing the critical information about MSK injuries, you will want to continue staying on the plain film theme and learning the arthritides. This topic is more about outpatient MSK imaging, but it is also critical for learning to become a consummate MSK imager. One classic book that I found very helpful is the book called Arthritis in Black and White. It is a classic, but it briefly summarizes the findings and distributions of different types of arthritides with pictures to help you out as well. You can read this one also during the first year of MSK or early in your second year.

Second Or Third Year

As a second and or third year, you also need an intelligible MRI MSK book that will give you all you will need to understand and interpret MSK MRI, a common area of difficulty in residency because of lack of exposure. Be careful not to buy the wrong book because many books make this fairly intuitive topic into something more complicated than necessary. So for this subject, check out Musculoskeletal MRI. I found this book “way back when” to be an excellent source for elucidating MSK MRI’s mysteries. It was one of my all-time favorite books in radiology because the author’s style is easy to read and logical. My residents still like it to this day.

Final Year

Finally, toward your last rotations before the core exam, you need some resources to fill in the blanks like bone tumors and MSK ultrasound. For these topics, many residents will look at MSK Case Series Review. Cases are the key to knowing the different types of bone tumors. If you want a more generic overall summary of these miscellaneous topics, you can check out the Musculoskeletal Requisites book.

All Years

Be sure to use a reference tool to check out normal variants, especially for the bones. Have a copy of Keats Normal Variants Atlas available when you read cases. You can also google your images, but it is easier to have a normal variant book handy. I often use this book when I am unsure if what I am seeing is pathological or normal.

Other Thoughts About MSK Imaging

In MSK imaging, especially, you need to be a little more definitive than other areas in radiology. If you see a fracture, call it a fracture. Don’t beat around the bush. You will find that Orthopedists and Emergency Physicians alike will need your final diagnosis to make their final treatment plans or surgeries. So, saying that you are not sure won’t cut the mustard unless, of course, there is real uncertainty in what you see on imaging.

Also, try to get to know your Orthopedists and ER physicians to determine how your calls correspond to what they see clinically or in surgery. Or, even better, examine the patients yourself after making a call. It is a great way to get to know if your diagnoses are correct.

And finally, for those who don’t have as much exposure to MSK MR, I would try to look at the cases that your attendings read on your own time. Then, compare your conclusions based on the history and images to the dictations of your attending. It’s a great way to learn what you need to know.

How To Be Successful In MSK Imaging

To become successful in MSK imaging, you need several ingredients. First, you need the right books (unfortunately, a lot of them for MSK!). It would then be best if you had the right attitude (coming down a little bit harder on diagnoses than some other subspecialties!) And then finally, you need a good point of reference for your calls (correlate with your patients, ER physicians, and Orthopedists.) If you utilize these resources, you are bound to become an excellent MSK imager!

Posted on November 15, 2020 by Barry Julius

How To Be Successful In Breast Imaging

In the second part of the “how to be successful” series, we will walk you through the ins and outs of the breast imaging rotation. Breast imaging, in general, is much different than almost any other area in radiology. (except for some interventional radiology) Why? Because the whole subspecialty hinges on management instead of differential diagnosis. Differentials are usually relatively limited and easy to remember. The challenging part of becoming successful in breast imaging is deciding what to do next. (As long as you don’t miss the finding!)

Also, there are multiple shades of gray in this area of radiology about how to manage patients appropriately. And, it takes a whole heck of a lot of experience to get good at it.

In any event, just like last week, let’s run through what you should read, what and when you should study the appropriate topics, and then finally how you should tackle learning for each year that you are on the breast imaging rotation.

Reading

First of all, I would highly recommend that you check out the free material from the ACR BIRADS atlas on the web. Here, you will get the most up-to-date resource to understand how we dictate breast imaging cases. Additionally, you will learn the appropriate semantics for all sorts of calcifications, masses, etc. I would also advise you to look for a copy of the paid atlas to see each of the different descriptors and associated findings. (see if you can find one lying around in your residency program because they cost 250 dollars!) These sources are the best way to understand the mechanics of reporting breast imaging modalities.

Furthermore, you should also have a supplemental reading to understand the rest of the gritty details about breast imaging. My residents have recommended Breast Imaging, the Requisites (I am an affiliate of Amazon for purchases when you click on the link) to do just that. Although reading during this rotation is required, it is a little less critical to function as well than some of the other radiology areas because it is so “experience-based.”

When To Study Topics In Breast Imaging

First-year

During the first year of breast imaging, I would recommend that you stick to reading out mostly screening and diagnostic breast imaging cases while reading the above resources. Why? It would help if you got acquainted with the basics of breast imaging. The basics include positioning/views, artifacts, searching for findings, and breast imaging’s basic mechanics. Try to hold off on doing too much interventional breast procedures until you are well acquainted with the imaging. You can check out a few to get your feet wet. However, the interventions may not make as much sense because most radiologists make the initial screening and diagnostic imaging findings to get to the intervention point. And, you need to understand these modalities first. You will benefit a lot more from understanding all the interventions better later on.

Second-year

Toward the end of your first rotation or beginning of your second rotation, try to be the initial reader on diagnostic mammography cases. Be in the position of deciding on the additional views and then run it by your attending. In mammography, the only way to learn is to handle parts of the cases yourself. If you don’t take charge, you will miss a good portion of the key to breast imaging- management. Also, be sure to enter the ultrasound room for all the breast ultrasound cases possible. Scanning patients will help you learn how to find lesions and what to look for when you find a mammography lesion.

Final residency years

For your subsequent months of mammography, you should make sure to learn how to perform stereotactic breast biopsies, needle localizations, and ultrasound guide breast biopsies. Also, this is the appropriate time to learn the basics of breast MRI. Breast MRI has become an integral part of imaging in the breast imagers arsenal. You need to understand its place and the basics of how to read them. Again, check out the ACR-BIRADS book for the reporting of MRI findings.

Finally, during your last year of mammography, learn all the new “fancy-schmancy delancy” add-ons. Learn about breast MRI biopsies, PEM imaging, or other modalities that may be unique to your institution. At this point, you want to fill in the blanks. Also, make sure that you have a mammography rotation during your fourth year of residency because the mammograms you read count toward MQSA requirements when you start reading mammograms after a one-year fellowship.

How You Should Learn Breast Imaging As A First Through Fourth Year Resident

More so than other specialties, breast imaging is not a “spectator sport” (a quote from my former chairman during my residency!). It involves being proactive in getting the experience that you need. Moreover, there have been a host of studies, specifically for mammography, that show you need to read tons of images to become an expert in breast imaging. So, you will have to be aggressive to get the numbers that you need to be successful in breast imaging. Not all residencies provide the same training in mammography, and some have significantly fewer cases than others. Therefore, this is a critical piece of the pie that you will need to become a consummate breast imager.

The Basics Of Being Successful In Breast Imaging

To summarize, what are the critical factors in learning how to become an excellent breast imaging resident and future attending? Ensure that you read the BIRADS atlas and a supplemental book such as Breast imaging, the Requisites. Start with reading screenings, ultrasounds, and diagnostic mammography. Then, when you are ready, take charge of your cases independently. Perform and learn about interventional procedures a little later. Then finally, fill in the blanks during the final years.

Also, I cannot repeat enough how important experience is for the breast imager. Writing down that you have seen “x” number of cases is not enough in the world of mammography. Make sure that you are looking carefully at each breast image. It is only with experience that you will feel competent enough to become a breast imager when you complete your residency. And, the best breast imagers have seen tens of thousands of cases!

Posted on November 8, 2020 by Barry Julius

How To Be Successful In Nuclear Medicine

For the next several weeks (and possibly months), we will start with a new theme: how to be successful in each of your subspecialty rotations. (and of course, today how to be successful in nuclear medicine!) Why should I even bother to tackle this theme? I mean, most residency programs have some guidelines about what residents need to do each month. Well, I can tell you that most of the time, these guidelines are only set up as a way to satisfy the needs of the ACGME and may not be all that relevant to what you need to know. Often, they are very boilerplate and merely copied from one institution to the next. Moreover, these summaries are “oh-so-boring” to read and likely outdated. Additionally, I aim to give this a bit more entertainment value (as I usually do!) and provide some more relevancy to what you actually should do on your rotations.

To organize this series, I am going to mirror the subspecialty rotations at our institution. At Barnabas (my humble program), we have a mix of modality and organ-based rotations. Now, you may ask, how can this be relevant to your situation if your program arranges your month slightly differently? Well, regardless of how it’s sliced and diced, you can infer many of the same themes at your institution. The information is still here to help you out. These include the books you need to read, how you should learn the material during each year of residency, and the actions to succeed in your rotations.

So, why start with nuclear medicine? Well, for one, it is my area of expertise. And, of course, what better place to start than my home base?

What You Should Read

Hands down, there is one resource that I like the most. It used to be Nuclear Medicine, The Requisites (which is OK). But all that has changed since the newest version of Mettler. (I am an affiliate of Amazon if you decide to click on the links and buy them!) I found Mettler to be comprehensive and reasonable to tackle. It was straightforward to read when I had to study for my recertification examination in nuclear medicine/radiology. Also, it covers most of the nuclear medicine topics. And I believe that is an excellent way to go.

When To Study Topics In Nuclear Medicine

During that first year of nuclear medicine, you need to first start by concentrating on the studies that can kill patients or cause severe morbidity if you miss something. What are these sorts of cases? These include V/Q scans (you don’t want to miss pulmonary emboli). Then, check out myocardial perfusion scans (you don’t want to miss ischemia from a left main coronary artery widow-maker lesion). Go through GI bleeding scans (you don’t want your patients exsanguinating). And finally, read about renal transplant scans (missing dying kidneys).

Then, next, you need to study what is most common when you’ve covered these bases. Of course, what occurs frequently can vary somewhat from institution to institution. But, for the most part, we are talking about bone scans, hepatobiliary scans, infection detection studies (gallium, indium-WBC, and Ceretec-WBC), and iodine scans for thyroid disease. Or perhaps, your institution may specialize in procedures such as parathyroid adenomas (as we do at ours). The bottom line is that you should study what you see most often to communicate intelligently with your attending.

Finally, you should study everything else. And, in nuclear medicine, that can be a lot. But, the core exam will pretty much cover most of nuclear medicine. That includes anything from PET-CTs of all types to DAT SPECT studies to evaluate Parkinson’s disease (or even the rare salivagram!) This order should allow you to be successful in your successive nuclear medicine rotations.

How You Should Learn Nuclear Medicine As A First Through Fourth Year Resident

First Year

Try to sit with your attending as much as possible at the beginning. Get a feel for what your faculty dictates and why. Then, without much further ado, be aggressive and ask to dictate cases as soon as possible on your own. Why? Because you want to convert what your attendings are thinking into a viable and logical report. That is what we do as radiologists. Without this skill, all your learning with be for naught!

Also, try to spend a little bit of time with the technologists. See how they operate the machinery. Check out how the patients undergo stress tests. Watch how the cameras work. All this observation is essential for understanding how technology translates into clinical operations and patient care.

Second and Third Years

During these years, you need to become a bit more independent. Now that you know some of the basics, you should try to pre-dictate cases even before the nuclear medicine attending arrives on the scene. Grab that bone scan and give it a whirl. What’s the worst that can happen? You will miss a few findings and learn something!

Fourth Year

Instead of only concentrating on the less complicated material, try learning the nuts and bolts of some more esoteric studies. Also, be sure to understand how the software works. You might need it at your first job. For instance, ask how your attendings process the PET-FDG brains for quantification. Or, maybe you should try to interpret some of the more arcane PET scans like Amyvid, Axumin, and Dotatate. Bottom line: this is your last chance to learn nuclear medicine before starting your fellowship. Maximize what you know before it is too late. You don’t want to be struggling with nuclear medicine’s nuances when you take your first job if they assign you to tackle that specialty.

The Basics Of How To Be Successful In Nuclear Medicine

Let’s be honest. Nuclear medicine is not the most formidable rotation of all. (A little biased coming from a nuclear guy!) Or, what I mean is that you are usually not worked to the bone. However, it certainly has its challenges.

To summarize, I would concentrate on those studies that have the most clinical impact first, dictate soon after starting, spend some time with the technologists, and be somewhat aggressive and attempt to preview and dictate studies when you are ready. This targeted approach is how I would proceed if I were starting anew. These guidelines can give you a bit of a boost when starting out and give you the tools to be successful in nuclear medicine. Go for it!

Posted on November 1, 2020 by Barry Julius

What Are The Consequences Of Postponing The Core Exam?

It’s no surprise that the ABR decided to delay the core exam. For years, they were unwilling to go virtual, even before Covid, claiming they needed their computers at the RSNA to give an appropriate “image-rich” examination. And, then, of course, they were not prepared at all when the Covid disaster struck. How do you force over a thousand residents to go to Tuscon or Chicago to take an exam amid Covid? In any case, now, this is water under the bridge. So, what are the real consequences to the current fourth-year residents of postponing the core exam? Will the damage be permanent? Here are some of my thoughts on this issue.

Less Time For Mini-Fellowship Studies

Mini-fellowships have been all the rage since the conversion from the oral boards to the core exam. One reason for this change was more time for residents to dedicate toward more independent learning during the final year. No longer did they need to study for a board exam at the end of the fourth year. Well, now this has mostly changed. Since the examination will be in February, you lose most of your fourth year for studying for the core exam again. (almost like the good old days of the oral boards.) Likewise, the time residents can concentrate on subspecialization without worrying about an exam will suffer.

More Time Spent On Learning Facts Of Equivocal Utility

It’s taken eons to get to the point I am today. I have spent years trimming the useless radiology facts from my brain and concentrating on what is critical. Now, the residents will begin this process a bit later than before. They will regurgitate some of the less useful information at the expense of the critical information needed to become a practical radiologist for several additional months. It’s having completed the core exam that would have allowed this process to begin earlier.

Postponing The Core Exam Will Cause A More Anxiety Filled Year

Residents will continue to spend the majority of this year in the “what-if” phase. What do I mean? They will continuously think about what will happen if they don’t pass the examination. A clear, calm head is much more conducive to enjoying the experience of residency. Test-taking prevents the settling down process.

Less Time For Gearing Up For Fellowship

Some residents like to begin to get ready for their next phase of training. That may mean reading a bit extra on their favorite subspecialty. Or, they may spend time practicing the nuances of bone biopsies if they are going into MSK. Now, residents will be less apt to increase their experiences in their future areas of interest. It’s much harder to concentrate on other topics when a test looms ahead of you.

Missing Out On The Full Fourth Year Experience (It’s Now A Four-Month Experience)

Finally, residents no longer receive the authentic fourth-year experience (However, I never had that as I studied for the oral boards!). It was kind of like an unwritten promise that you will have a great last year if you complete and pass the core examination. Now, it is back to the grind for the majority of the year.

Postponing The Core Exam: Is It The End Of The World?

The short one-word answer to this question is NO! However, for every action, there is a consequence. And postponement of the exam is no exception. After a tough three years, it is a bit of a slap in the face for residents. Many of you have paid to have a great fourth year of residency with blood, tears, and sweat (literally!), working diligently during your training. “Fourth-year” will now only last a few months after the exam.

Nevertheless, remember, in the end, all of you will still become radiologists. Life always throws a few curveballs. And, your residency will become no more than distant memory soon enough!

Posted on July 5, 2020July 5, 2020 by Barry Julius

Top Eight Radiology Residency Changes Since The Pandemic

After

Both unemployment and more remote working have taken a toll on the number of cars on the road. You can now enjoy speeding into your rotations in the morning. It is harder to blame being late on the traffic. See, there are one or two benefits to this unfortunate pandemic!

Radiology Residency Changes- A New Way Of Life

It’s remarkable to see the myriad of radiology residency changes in our daily lives. Only four or five months ago, Covid-19 was barely an afterthought. Now, it encompasses our whole way of being. And radiology residency is affected just like everything else!

Posted on April 19, 2020April 19, 2020 by Barry Julius

How To Mitigate The Next Pandemic: Encourage New Physicians To Get Business Training!

Crises have a habit of magnifying gaps that we could not have imagined beforehand. And, this Covid pandemic reveals these large cracks in our healthcare system by the dozens. We have seen hospitals and imaging centers functioning without physicians receiving the appropriate personal protective equipment (PPE). We are witnessing a lack of ventilators for our sickest Covid patients. Moreover, we are beholding our healthcare system, reliant on lucrative elective procedures, go sour. Practices, hospitals, and imaging centers temporarily are almost empty (other than Covid patients) and dependent on our government to stay afloat. And, these issues are just the tip of the iceberg.

Did these misfires have to happen? Could leadership have prevented the dramatic shortfalls that we are experiencing now? How can we have known our future? Well, it’s a matter of ill-preparation. And, this pandemic was not on the radar. But why? For years, many intelligent folks have been warning about preparations for pandemics. (check out this TED talk by Bill Gates) And, it is not just him. Other brilliant scientists and doctors have warned us about preparing for the next pandemic. No one listened.

Reason For Health Care’s Poor Preparation For The Current Pandemic

Why did hospitals and our healthcare system ignore prescient information sitting right in front of their noses? Well, it has to do with the model of healthcare that we follow in this country. We have been treating healthcare as just a business for years. And if you think about it only in these terms, the situation that we are in makes sense. Why would you prepare for calamity if it’s going to decrease your short-term and intermediate-term profits? Preparations reduce your bottom line.

But herein lies the crux of the problem. We can’t just think of healthcare as a business, but also as a way to protect and serve people. To accomplish this task, we have charged the wrong leaders with the responsibilities of running our healthcare system. Having only a JD or MBA, although helpful for understanding the business of medicine in the short term, is not enough. We need leaders in charge who have also been in the trenches and understand what our physicians and patients need in the long run. They need to understand the science and art of medicine. For these reasons, I would argue that we need more MDs and MD/MBA types in administrative leadership positions. With physicians in charge, hospitals could have prevented many of these issues.

Examples Of Why Physician-Hospital Administrators Would Make Better Health Care Administrators/Leaders

Let’s take some of the examples I provided above. PPE and ventilators are examples of two expenses that make no sense for a hospital to buy if you are thinking only about the business of medicine. First of all, buying such equipment would attract patients with infectious diseases to your institution because you have the equipment to manage only the sickest of patients. These patients cost more to the hospital. Additionally, why buy ventilators or PPE if you don’t need them now?. For-profit and non-profit institutions lose money off of their balance sheets, thereby decreasing bonuses given to their leaders. We can no longer think in these terms.

Or, let’s think about elective procedures as a way for hospitals to make money. Does it make sense? No. In a pandemic, the profit centers of a hospital shut down, causing the government to have to bail them out. Instead, healthcare profits should be made based on treating patients for sickness and making them well. Who better than a physician with some business sense to change this system so that we begin to treat patients and not just increase short term hospital cash flow?

The Answer: Encourage More Physicians/Radiologists To Receive Business Training

I want to underscore that we do need folks with business minds in charge of our healthcare institutions. However, these folks should be the doctors as leaders who can understand both business and medicine. To know how to run a healthcare system, you need experience in the trenches, both in the corporate world and medicine.

So, we, as program directors, mentors, and faculty, should encourage our residents to learn more about hospital administration. Instead of dismissing those residents that are not following our clinical footsteps, we should guide these new physicians on how they can begin this new pathway. Business courses should not be just an afterthought or tack-on to the radiology curriculum.

We need to start thinking differently about what and how we teach about the business of medicine. Let’s start taking more seriously some of the excellent curricula that the ACR or other physician societies offer and create mandatory externships to learn more about healthcare administration. Or maybe, just like informatics or MSK, all specialties should have fellowships dedicated to hospital administration. Now is the time to create easy-to-follow health care administrative pathways for our residents. It’s more than just creating another silly specialty pathway; it’s the future and viability of the entire healthcare system at stake!

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