Job hunting - but they want an U/S fellow...

hey there folks:

So, I'm job hunting and have some very particular places that I am really interested in due to geographic and career goals. Note: I'm looking for an academic job.

I have sent CV and letter of interest and had conversations either in person or via e-mail with the heads of the departments. Both have said that "there is no position available". However, I also know another person who is at a similar point in their career (but with an ultrasound fellowship) who is also applying to these same places and has interviews with them scheduled and has clearly been told that there is an opening.

There are public job postings out there as well from these places. So two questions.
- Is it a really bad sign that they've reviewed my stuff and are telling me there's no position, when obviously there is? Are they really saying "there's no position... for YOU." If so... why not just be honest about what they're looking for?
- I have a strong background in ultrasound myself, but no one seems to care since I'm not fellowship trained. I was debating taking the RDMS exam to try to make myself more marketable, since to me it looks like these places are specifically looking for ultrasound people (graduating residents, let this be a lesson to you! I disregarded my husband's suggestion that I do ultrasound fellowship because it would be in demand, because "I already know a lot of that stuff, why would I do a fellowship in it"... sigh). I think I could pass the exam with a few weeks of studying up on the physics stuff. What do you think? I'm assuming it's not my personality or some other factor that is making these places say no to me .... hopefully.

Hmm, that's tough ... If you really think it would help you, you could try to do an RDMS. But I think the point about hiring someone who is ultrasound-fellowship-trained is that a a) US fellowship offers other kinds of "training" that is over what residency involves and b) at many academic centers, they want their "director" or section faculty to have the appropriately documented training (ie. a diploma from a fellowship program).

This is going to probably be increasingly more important when ultrasound becomes ACGME accredited, which looks like will happen over the next few years. There are residencies that are very strong in ultrasound (like it sounds like yours was), and there are still many residencies that are weak in ultrasound. Fellowship completion right now offers some documentation of expertise meaning proficiency in basic US but also advanced US, experience with US publication +/- grant-writing, familiarity with or connections with US leaders, familiarity with how to manage and run faculty/resident QA, education organization, familiarity with the US billing process, etc. So it seems these aspects outside of ability to perform high quality ultrasounds are what many academic places are looking for.

quinsy said:

hey there folks:

So, I'm job hunting and have some very particular places that I am really interested in due to geographic and career goals. Note: I'm looking for an academic job.

I have sent CV and letter of interest and had conversations either in person or via e-mail with the heads of the departments. Both have said that "there is no position available". However, I also know another person who is at a similar point in their career (but with an ultrasound fellowship) who is also applying to these same places and has interviews with them scheduled and has clearly been told that there is an opening.

There are public job postings out there as well from these places. So two questions.
- Is it a really bad sign that they've reviewed my stuff and are telling me there's no position, when obviously there is? Are they really saying "there's no position... for YOU." If so... why not just be honest about what they're looking for?
- I have a strong background in ultrasound myself, but no one seems to care since I'm not fellowship trained. I was debating taking the RDMS exam to try to make myself more marketable, since to me it looks like these places are specifically looking for ultrasound people (graduating residents, let this be a lesson to you! I disregarded my husband's suggestion that I do ultrasound fellowship because it would be in demand, because "I already know a lot of that stuff, why would I do a fellowship in it"... sigh). I think I could pass the exam with a few weeks of studying up on the physics stuff. What do you think? I'm assuming it's not my personality or some other factor that is making these places say no to me .... hopefully.

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Maybe someone with more of an academic insight would have a better answer but I think the RDMS certification would give you more credibility as having the expertise. I'm in a 4 year program and am taking the first part of the RDMS exam while I'm in residency. Essentially, most people do the ultrasound residency to give them the #800 scans and training to be able to get RDMS certified which looks good and gives you that niche, but I think if you have them already and qualify to sit for the exam, a fellowship would be a waste. It's hard to look at someone's CV and see #800+ scans, with RDMS certification and argue that they don't have enough ultrasound experience to start an ultrasound program or find an ultrasound niche in their academic program.

For the residents.... If you've got time to do this... I really think it's worth it. Easier to pull off in a 4 year residency vs a 3 year, but #800 can be gotten with good habit forming and persistence. You need #800 scans while in residency to be able to sit for either of the RDMS exams (1 is physics, 2 is based on your area....abdomen makes most sense for EM folk.) You can only take the physics exam while in residency, but you have to have all 800 scans and be signed off by someone with RMDS cert and you have to have a letter from your PD. The 2nd exam, you can take right after you graduate, so if you studied for it, you could technically take it the day after graduation. It would be essentially getting the majority of the benefits of an ultrasound fellowship without having to do the fellowship itself. Even if you don't do academics, I think it would be valuable in any private practice group. You could be the "ultrasound go to guy/gall", plus educate them on increasing RVU's based on ultrasound guided reimbursement. Know how much an ultrasound guided peripheral IV charges? Around 200 bucks. I'm not saying you should slap a probe on everybody's antecubital fossa to buff up their bill, but I'm just giving an example. UTZ compensates very well when you use it frequently whether that be through limited ED exams that you can bill for, or any UTZ guided procedure, no matter how small. Gonna do that ulnar nerve block to fix the boxer's fx? Use UTZ! I did one of those last week and not only is it good for improving efficacy and precision of the procedure, but it bills very nicely. Not that I'm making any of that extra billing as a resident...

Anyway, hope you get more interviews, but if you can get RDMS, it almost seems like an ultrasound fellowship would be overkill. Do you have over #800 documented from residency?

RDMS certification and ultrasound fellowship are two very different things. Both are valuable, but very different.

RDMS focusses on image capture along with knowlege of the mecahnics and physics of ultraosund. There is little to no training in application or interpretation. It really is a technical certification.

An ultrasound fellowship is much broader training that focusses on all of the above plus interpretation, application, education and teaching, and quite importantly research.

Academic places often look to hire people to fill a niche in which they are under-represented - i.e. an educational person or an EMS person or an investigator, etc. Often they are looking for expertise in a certain area to add to the group. More and more, academic places are looking for fellowship training. A young physician who has limited their clinical practice hours in order to focus on ultrasound for a year and trained under an emergency ultrasound guru is going to be way more prepared to lead an academic department in ultrasound than a young physician who has done a lot of scans during residency, is very familiar and interested in ultrasound, and has an RDMS certification.

This may help...

ACEP's primer on Ultrasound Fellowship:

III. Minimum Criteria to be a Fellowship Director:
1. If not fellowship trained, the director should have at least three years of ultrasound use in clinical practice after residency training.
2. A fellowship-trained person should not direct a fellowship for one year following completion of their fellowship. A fellowship-trained physician should not start a new program from the ground up for at least two years post fellowship.
3. Publish at least three peer reviewed emergency ultrasound articles in Medline indexed journals.
4. At least two of the above mentioned publications must be original ultrasound research with the emergency ultrasound director as first author on one of them.
5. The third ultrasound publication can be a review article for a Medline indexed journal.
6. The emergency ultrasound fellowship director must utilize all of the clinical ultrasound applications listed in the most recent ACEP Emergency Ultrasound Guidelines http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32878 and have experience in more advanced applications.
7. The emergency ultrasound fellowship director must have at least four regional and national abstract research presentations at meetings conducted by organizations such as ACEP, SAEM, American Institute of Ultrasound in Medicine (AIUM) or similar meetings over a three-year period, or must be intimately involved in advancing emergency ultrasound by actively participating or leading one of the previously mentioned nationally recognized organizations in regard to emergency ultrasound.
8. The fellowship director should have a record of excellence in teaching. This ability can be demonstrated by teaching awards, consistently favorable evaluations by residents and/or fellows, or the like.
9. The criteria to be a fellowship director are intended to be used for emergency ultrasound fellowship guidelines only, and are not intended to be standards for teaching residents. These criteria should not affect resident teaching programs.

IV. Fellowship Minimum Criteria for Graduation:
1. A minimum of 1000 ultrasound examinations must be performed by the emergency ultrasound fellow per year by him or herself. Quality assurance review of other’s ultrasound examinations or observing actual ultrasound examinations performed by others will not count toward this number. T This number serves more as a minimum guide as it is understood that with more hands-on experience one becomes more proficient. It is preferable however to utilize an objective tool to assure competence in all aspects of emergency ultrasound upon completion of the fellowship program. Supplemental written and practical exams might be considered.
2. The emergency ultrasound fellow should design at least one research project to be submitted to the home site institutional review board and start on it during the course of the fellowship.
3. At least one abstract should be submitted with the fellow’s name as first author and presenter to a national meeting such as ACEP, SAEM, or AIUM during their fellowship.
4. The emergency ultrasound fellow should be involved with at least one other ultrasound research project (does not have to be one he/she designed and implemented from the ground up) during their fellowship for which publication is planned with the fellow as an author.
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5. The emergency ultrasound fellow must be involved with the various admistrative and quality assurance duties involving emergency ultrasound. Such duties include but are not limited to internal billing audits, interdepartmental meetings, and monitoring the credentialing process of colleagues.
6. The emergency ultrasound fellow must prepare and deliver lectures on at least four separate topics on the basic emergency ultrasound applications to their department (residents and faculty). The emergency ultrasound fellow should be encouraged to prepare and deliver at least one lecture on an advanced or novel application.
7. The emergency ultrasound fellow must show at least 20 hours per month of hands-on teaching of residents and/or other faculty in bedside emergency ultrasound. This includes but is not limited to didactic lectures, bedside teaching, research involvement of residents or faculty, and QA education.
8. The emergency ultrasound fellow must attend one national emergency ultrasound organization meeting during the year.

Notice, there's actually not ALOT needed relatively speaking to get the qualifications for both Director or Graduated Fellow. It's mainly about the scans which obviously goes along with training, but remember, Ultrasound fellowship is not meant to teach you how to read a diagnostic study so that you can read your own Ultrasounds. Even if you're RDMS, you're never going to diagnose something "officially" based on your Ultrasound study. The radiologist will. RDMS is about gaining the proficiency to perform the actual exam, understand the anatomy, pathology vs normal variants, etc.. Obviously there's some diagnosing going on there but notice that most of the requirements revolve around gaining expertise with the machine, raw number of scans and academic involvement.

I'm at a pretty big academic institution and both of our ultrasound directors are neither RDMS certified, but they both have the requirements that ACEP lists to be directors. One is about to get his RDMS though...

I really think that if you have plenty of scans and can get the RDMS out of the way, it's the academic involvement that might be the only hindrance to giving you some additional credibility, but you could involve yourself in something at just about any institution. If you don't have the scans, nor the academic involvement, then sure... might be best to do the 1yr fellowship and get it all out of the way easier.

It's not really all about the RDMS. RDMS is just a sonographer's qualification. It's just an exam stating that if you have about the same basic training and passed the same basic examination as an ultrasound tech does. You don't need a fellowship to do your RDMS, and for those who can do it, getting the RDMS during or right after residency is encouraged.

Fellowship training doesn't have much to do with the RDMS. Plenty of fellowship-trained people don't bother with the RDMS (although it is generally encouraged that a fellow do it, along with perhaps the RDCS and maybe the new RMSK). Faculty who are fellowship-trained within academic centers' US Division or US Section don't necessarily have to have the RDMS.

The ACEP guidelines seem rather regimented, but I agree with generally their commitments re: what the fellowship provides. I will argue that having an ultrasound fellowship DOES teach you how to read your own ultrasounds DIAGNOSTICALLY. And this is where it comes into the ability to bill for your scans (right now, it's aorta/efast/echo) and for fellowship-trained people, hopefully soon to add renal / biliary / pelvic. Of course, the area of billing is a little up in the air right now as it is hospital-dependent.

Academic centers will probably want fellowship-trained people. However, there are jobs at community-based (but academic as residents rotated there) programs for which you can be an ultrasound director without a fellowship requirement.

Coming from a guy with RDMS after my name, don't get hung up on this credential. While it seems that taking the test is expected at many fellowships, that isn't universal. The reason for this is as stated above. It really says nothing about image interpretation, which is a critical aspect of emergency physician performed ultrasound. The other ultrasound fellowship trained partners in my group do not have the RDMS credential and I consider them better emergency sonographers than myself. I also find that many people are not even familiar with what these letters mean.
What fellowship does provide and what is sought after by academic and community groups is experience in teaching and QA. Every group with an US machine in their department has to have an ultrasound director who is responsible for oversite, image archival, and QA. Some places are good with this person being non-fellowship trained. However, many bigger groups are looking for someone with specific experience in these areas.
If you are looking to find a job as the ultrasound guy somewhere, make sure you do some research on the specifics of what is required. Frequently, this is not laid out explicitely.

Thank you for the advice so far.

I had 1200+ QA'd scans during residency so that part is not a problem, I can get a letter from the ultrasound division chief to that effect.

I agree with your points that RDMS is not the same as fellowship training, just feel like people aren't taking me seriously because even though I have "1200+ QA'd scans" on my CV, I'm not sure the people reading the resume really know what my training was like or are even paying attention to that. I figure even if an ultrasound fellow would know the difference, or anyone who's really in on the deal, the people looking at my resume are the department chairs and these people just like to see things like letters after your name.... know what I mean?

It isn't clear that they are specifically looking for an ultrasound director, and I don't really want to be ultrasound director (although I would do this if it meant I got my dream job otherwise!), but I thought I could bill myself as support faculty for ultrasound. After all, to do a whole residency and faculty with training/1-on-1 scanning and QA/tape review, you need more than 1 person...

I think I'm going to give it a shot... if you have any tips on good study guides please let me know.

uncwalley said:

What fellowship does provide and what is sought after by academic and community groups is experience in teaching and QA. Every group with an US machine in their department has to have an ultrasound director who is responsible for oversite, image archival, and QA.

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In the past 3 ERs where I have worked post-residency, there is no image-retrieval process, or storage process. I use it like a stethoscope with granted privileges in FAST, Aorta, RUQ, and pelvic. My group bills for the ultrasounds, has no ultrasound director, no image rerieval, and no QA. Its awesome.

We are shooting ourselves in the foot as a specialty by pushing the boundaries of ultrasound. When boundaries are pushed, the radiologists in the hospital demand more oversight, image retrieval, storage, QA, etc. The extra revenue brought in by billing for ultrasound is destroyed in paying the US person. The extra time actually saving, labeling, and down-loading the images make it even less time efficient.

All hospitals are going to let you do FAST. If I simply have privileges for FAST, I can do a FAST on anybody, for any reason, and just happen to look at their gall-bladder to help me on my differential diagnosis and decrease or increase my threshold to order other imaging modalities. I don't have to mention anything about the gall-bladder anywhere on my documentation. If it is a pregnant lady, I can do a FAST, and if I happen to see an intra-uterine pregnancy on the bladder scan, she can wait in the waiting room for her for the ultrasonagrapher to come get her after her blood is drawn for an RH and can return there for and scan result, lab results (UA) and disposition. The argument for more bedside ultrasound is that you get quicker results, faster dispositions, and more money. I'm not sure that is true in real practice, and I can see ways to accomplish the goals without having an uber-big, wasteful ultrasound program. The way to get radiology to let us do ultrasound is by getting the techs up at night repeatedly for every single gall-bladder and pregnancy. I'm advocating a more passive-aggressive approach to accomplishing our goal of unfettered use of ultrasound.

Residency Programs need ultrasound teaching as part of the curriculum, so fellowships are a must to give you that extra knowledge needed to teach. Therefore, I see the utility in fellowship training for those people. However, please don't think that you are going to be more competitive as an ultrasound geek in community medicine. There are certain groups looking for that, but wasting a year on an ultrasound fellowship when you don't plan on doing academic medicine seems silly.

Obviously, this is just my experience. How many of you guys in the community have QA, image retrieval, an ultrasound director, etc.?

Quinsy: I used the test prep software from Davies Publishing. I also went through a couple texts, but I don't remember which ones.

Jarabacoa: Billing without image archival is a no-no. At this point, what image is archived is not defined, but there has to be something showing "relevant anatomy/pathology". For IV placement, there is a requirement of image of needle entering vein. Of course, you will only get into trouble if you are audited, but I wouldn't take the risk.
Whether having an ultrasound program is actually cost effective depends on how many ultrasounds your group does and how much your US director gets paid. It usually isn't a huge amount.
Whether or not you save time with US also is dependent on how you use it and how fast you are. There are studies that show that it does decrease LOS, especially at night if there is no in-house tech. I believe that plays out differently at different sites.
Finally, I agree that a fellowship is not necessary to run a community ultrasound program, just as an EMS fellowship is not absolutely necessary to be the director of an EMS system. The same can be said for college degrees in many cases. The greatest benefit of the fellowship is for those with academic goals, but it does have value in any case. What one gains in a fellowship would have to be found on the job otherwise. It can be done and has been done very successfully, but it is more difficult.

Jarabacoa said:

In the past 3 ERs where I have worked post-residency, there is no image-retrieval process, or storage process. I use it like a stethoscope with granted privileges in FAST, Aorta, RUQ, and pelvic. My group bills for the ultrasounds, has no ultrasound director, no image rerieval, and no QA. Its awesome.

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Um hmm, it seems this is what could really get you in trouble. For billing purposes, you need documentation of an image. They can be stills, doesn't have to be clips, but something that says you actually did what you said you did. Otherwise, this can be construed as fraud... You don't necessarily need a US director or QA, but you need an image. It's hard to believe that your coders / billing department hasn't communicated this with you because these ultrasounds we bill for have their own separate procedural codes.

And whether we keep expanding our scope of practice regarding US isn't really what's shooting us in the foot. If it is, then we should be sticking with only the "authorized" applications (Fast, Aorta, Echo) right now... but no, we do RUQ/pelvic/dvt/ocular/MSK because a lot of it is applicable to speeding up our downstairs ED processes. One of their main beefs is that they cannot see us following a standardized, accredited process and this is something that will change in the near future with ACGME accreditation.

I could go on and on about beefs between radiology and ED use of point-of-care US. But it's like comparing apples with oranges. Radiology residents are never taught how to actually use the machine and if they are, they are never as extensively taught as we are. They still rely on techs performing still images and never review in real time, etc etc etc. However, our "unstandardized" training with loose ACEP guidelines is an issue that the ED needs to address, and this is being actively pursued by the ACEP EUS section.

Bottom line is that we aren't going to shoot ourselves in the foot by "doing more" as Jarabacoa suggests, but as US advances, we will find more an more applications for ED use - these will have to be standardized. What will shoot us in the foot is if we stop seeking ways to improve ED efficiency and this premise is ultimately drives ED expansion of skills/imaging/etc. I attach a recently published article (extremely poorly done) which outlines some of the radiology biases. And this is from a group who a decade ago opposed EDPs of doing Fast / aorta / echo.

What exactly does it say in the CPT code about storing images? You are probably right, but my boss just told me last week that we didn't need stored images. Again, the more aggressive we are with billing and ultrasounding everybody, the more CMS is ultimately going to meddle in our affairs. Right now, the government isn't wasting their time auditing charts and looking through image databases looking for fraud, but continue with the ultrasound obsession, in hopes of maximizing billing and soon they will.

I agree with the following author:

http://journals.lww.com/em-news/Ful...de_Ultrasound__A_Wrong_Turn_Somewhere_.9.aspx

leorl said:

Radiology residents are never taught how to actually use the machine and if they are, they are never as extensively taught as we are. They still rely on techs performing still images and never review in real time, etc etc etc.

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From where do you get this? If you are extrapolating this from just where you were a resident or are a fellow, it is not true, as a good friend of mine, who is a radiologist, told me that she was indeed trained on the ultrasound, as well as she knows how the plain films, CT, MRI, and SPECT scanners all operate, and that she could, in a rudimentary way, run them, although that would be foolhardy. Her program taught her this, so all the residents knew, and it was a mid-range program, but, without further data, I would wager that rads residents are taught technique, and against that they are NEVER taught. And, really, not taught as extensively to use the machine as we are? Really? Technically, how much is there really to know? Knobology isn't earth-shattering.

Sure, so are we. Radiology has rudimentary training in US - from radiology residents I've spoken to, that might include 1-3 days of hands on. Can someone with 3 days of hands on training really feel confident to performing all the POC applications that we do? Hardly. We have continuous training in US (or you're supposed to in residency) with anywhere from 2 weeks to 1 month, and then continuous usage during residency. By "no training," I mean that they can't perform US themselves in real-time and with confidence as to what they're looking at. I don't mean knobology or basic principles. I still think that comparing radiology US to ED POC US is trying to compare apples to oranges.

jarabacoa, I'll ask our coder here if the billing/coding dept can give me an example of US codes

- oh, just ran into the coder. So she gives an example of 93308 as a CPT code for Echo. If your place is billing separately for Echos with the CPT codes, there needs to be image storage / documentation of images. If you are just using it as part of an E&M (evaluation tool), they don't need necessarily documentation but then you can't bill for it separately.

I agree with that link somewhat. There is a difference and disconnect between community and academic use of US right now, and the use of ultrasound is going to vary depending on needs of the hospital and the needs of that hospital's population. I find my daily use of it is helpful to me, and has resulted in practice interventions on a number of occasions. I and probably many in the US community don't actually care whether there is an actual financial incentive. Unfortunately, especially in financially strapped academic settings, ED administration is what dictates billing, and therefore if they want to set guidelines for billing purposes, this is what it becomes.

leorl said:

I still think that comparing radiology US to ED POC US is trying to compare apples to oranges.

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Really? Seriously? You looking at the uterus, and the tech looking at the uterus (or the GB, or the leg vessels) are THAT different? Please explain, as I don't see it as "apples and oranges" at all, in no way, full stop.