competetion crazier than ever

[navigator420]

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Getting indications from a couple of programs that the number of students intrested in radiology has increased substantially this year . is this one of those pre application jitters, just looking for some insider information

 

[doepug]

Hold on... no program has received a single application yet. I'd ignore any rumors about competition or anything else until the season is underway. Even those in the know (e.g. program directors) won't really know anything until ERAS opens, so hang on... we'll see what happens. At my program, competition has remained pretty tough, but we've pretty much hit a plateau in terms of number of applicants. We'll see how this year goes.

Hang in there,
doepug (pgy 4 / radiology)

 

[IheartCaffeine]

Hold on... no program has received a single application yet. I'd ignore any rumors about competition or anything else until the season is underway. Even those in the know (e.g. program directors) won't really know anything until ERAS opens, so hang on... we'll see what happens. At my program, competition has remained pretty tough, but we've pretty much hit a plateau in terms of number of applicants. We'll see how this year goes.

Hang in there,
doepug (pgy 4 / radiology)

Sorry, totally off topic:
So PGY 4 huh? How is rads 4 years later? Is it what you expected? Are you happy you made that decision?

 

[doepug]

Sorry, totally off topic:
So PGY 4 huh? How is rads 4 years later? Is it what you expected? Are you happy you made that decision?

Very happy with radiology... best field in medicine in my opinion for many reasons. Medical imaging has replaced the physical exam, and radiologists have become indispensable for even the most fundamental diagnoses. Even with turf battles and political pressures, the future of radiology is bright.

 

[dralex]

doepug, yes radiology may be the best field in medicine but diagnostic imaging has not replaced the physical exam. The history and physical are still and will always be the most important part of diagnosis.
Until the day comes when a star trek type medical tricorder comes out you will always have to do a physical exam of one sort or the other.

 

[Sureshot83]

It is certainly an overstatement to say that imaging has "replaced" the physical exam. I'm just an MS-3, but this exact issue actually came up on my internal medicine rotation this week.

No physical exam --> My intern doesn't find a random abdominal mass completely unrelated to the pt's chief complaint --> Patient never gets sent for an abdominal CT --> Radiologist never sees a 15 cm (yes, centimeter) mass consistent with lymphoma.

We're waiting for biopsy results now. Without my intern's thorough physical exam, this guy would have been sent home after his not-so-serious chief complaint resolved.

 

[f_w]

Until the day comes when a star trek type medical tricorder comes out you will always have to do a physical exam of one sort or the other.

We already have a tricorder:

http://www.gehealthcare.com/usen/ct/products/vct.html#

In the day to day reality, imaging and labwork unfortunately lead to atrophy of clinical exam skills. While I would hope that '85% of diagnosis is in the H+P', it seems these days that '85% of diagnosis is in a shotgun workup ordered by a PA before the patient is even seen'.

 

[dralex]

Well, I don't think the new volumetric CT quite fulfills the role of a "medical tricorder" but it's a great product.
A true "tricorder" type of device would do anatomic and physiologic scanning.
Someday we may get there, but not anytime soon.
In the meantime don't forget your H&P skills!
Shotgun workups are tough, not only expensive, but if you do enough labwork on someone you are bound to find some abnormality that may not be a big deal but will lead you down the path of obtaining even more followup studies.

 

[f_w]

Shotgun workups are tough, not only expensive, but if you do enough labwork on someone you are bound to find some abnormality that may not be a big deal but will lead you down the path of obtaining even more followup studies.

It is known as the 'death spiral'. It usually starts with a non-indicated abdomen/pelvis CT for (pick one) hematuria/abd pain/bloating. On the portion of the lower lung included on the abdomen, we run into some sort of non-calcified nodule. This nodule is now diligently followed with chest CTs. Eventually, we find some nonspecific looking infiltrative process which prompts a pulmonary consult. And, if you have a hammer, everything looks like a nail--> bronchoscopy --> delayed extubation --> nosocomial pneumonia.......

Don't underestimate the killing power of non-indicated tests.

 

[dralex]

Don't underestimate the killing power of non-indicated tests.

So very true...

Back to the OP and the intitial topic. Radiology is a hot field and with good reason. But as doepug stated right now there is no way to tell what the interest is for this year. Don't panic!

 

[hans19]

It is certainly an overstatement to say that imaging has "replaced" the physical exam.

You haven't met our ER docs yet.
Me: "Is she actually hurting in the right lower quadrant?"
ER: "Oh we haven't seen the patient yet. Besides, we consulted surgery, and they won't see the patient until the imaging is done first."

No physical exam --> My intern doesn't find a random abdominal mass completely unrelated to the pt's chief complaint

There are many more times where the radiologist makes a serendipitous finding on imaging that ends up being significant, than the clinician finds on physical exam.

We're waiting for biopsy results now.

Was it a CT guided biopsy?

Are you worried that the patient has had a heart attack? Check the Troponin, Failure? BNP? Diabetes? A1C/glucose

Very few diagnoses are clinched without imaging, or some lab test of some sort.

 

[ScooterBanks]

We keep forgetting that everyone is on the same team.

Sometimes the clinicians will pick up things and order imaging, sometimes radiologists will spot things that could not have been reasonably seen otherwise.

I have no problem reading studies to try and figure out what's going on. I could care less if clinicians do a half hearted physical exam most of the time. The thing that bugs me, and what Hans alluded to, is the fact that so much imaging is being ordered without giving the radiologist any clue as to what's going on. If everyone is on the same team, then the clinicians need to do a little better job localizing some of the patients complaints so the radiologist can focus more on the pertinent areas.

For example, I hate it when an old gomer falls and the ER orders plain skull films, sinuses, facial bones, c-spine, chest, rib views, then bilateral hips, knees, ankles, feet, and hands on the same person and then writes "fall" on my requisition! There is no way I have the time to thoroughly check 12 different studies on the same person with everything else going on while on call. At least ask the gomer where he's hurting, order appropriately, then give me a 30 second call to say "he's complaing of neck stiffness, right knee, wrist and second metacarpal pain". You don't even have to do a physical exam...just a two minute history. Everyone wins. It doesn't waste my whole night, I can look closer at the spots where the guy actually has symptoms, the old dude gets better care, and the ER doc ultimately gets a faster turnover time.

ER docs have learned over the years that if they go ahead and order a bunch of imaging, it places the legal burden of missed findings onto the radiologist and away from them. I think many modern ER ordering patterns are just as much of CYA medicine as they are laziness or lack of knowledge.

 

[Sureshot83]

There are many more times where the radiologist makes a serendipitous finding on imaging that ends up being significant, than the clinician finds on physical exam.




Was it a CT guided biopsy?

Are you worried that the patient has had a heart attack? Check the Troponin, Failure? BNP? Diabetes? A1C/glucose

Very few diagnoses are clinched without imaging, or some lab test of some sort.

I certainly did not mean to imply that radiologists never make unexpected yet serious findings, or that a good H&P will 100% seal the diagnosis. I was just making the point that imaging has not replaced the H&P, which was the original claim. If your ER docs are ordering a full body CT scan for anyone who falls, or refusing to examine patients until expensive imaging tells them what to look for, then quite simply, they are not practicing good (and cost-effective) medicine

 

[montypython]

I certainly did not mean to imply that radiologists never make unexpected yet serious findings, or that a good H&P will 100% seal the diagnosis. I was just making the point that imaging has not replaced the H&P, which was the original claim. If your ER docs are ordering a full body CT scan for anyone who falls, or refusing to examine patients until expensive imaging tells them what to look for, then quite simply, they are not practicing good (and cost-effective) medicine

And ER doc's wonder why other doc's refer to them as glorified triage nurses and "which" doctors when they use this shot gun approach to medicine.

 

[f_w]

If your ER docs are ordering a full body CT scan for anyone who falls, or refusing to examine patients until expensive imaging tells them what to look for, then quite simply, they are not practicing good (and cost-effective) medicine

Welcome to the real world.

btw. ER docs don't practice medicine. They practice 'emergency medicine' (the kind of medicine you only want to rely on in an emergency, kind of like the 'emergency brake' on your car). Being correct in your diagnosis is not so important as being in a defensible position (defend against the surgical service that doesn't want to admit, the specialist who doesn't want to consult, the jury of 12 village idiots that might decide your fate).

Here is e-medicine in a nutshell for you:

(Lengh of stay)/(odds of getting sued)= 'quality of care'

 

[scully]

For example, I hate it when an old gomer falls and the ER orders plain skull films, sinuses, facial bones, c-spine, chest, rib views, then bilateral hips, knees, ankles, feet, and hands on the same person and then writes "fall" on my requisition! There is no way I have the time to thoroughly check 12 different studies on the same person with everything else going on while on call. At least ask the gomer where he's hurting, order appropriately, then give me a 30 second call to say "he's complaing of neck stiffness, right knee, wrist and second metacarpal pain". You don't even have to do a physical exam...just a two minute history. Everyone wins. It doesn't waste my whole night, I can look closer at the spots where the guy actually has symptoms, the old dude gets better care, and the ER doc ultimately gets a faster turnover time.

If they don't call you, do you ever call them for more history or clarification? I will be taking call soon enough, and am wondering how you handle these situations.

 

[IheartCaffeine]

For example, I hate it when an old gomer falls and the ER orders plain skull films, sinuses, facial bones, c-spine, chest, rib views, then bilateral hips, knees, ankles, feet, and hands on the same person and then writes "fall" on my requisition! There is no way I have the time to thoroughly check 12 different studies on the same person with everything else going on while on call. At least ask the gomer where he's hurting, order appropriately, then give me a 30 second call to say "he's complaing of neck stiffness, right knee, wrist and second metacarpal pain". You don't even have to do a physical exam...just a two minute history. Everyone wins. It doesn't waste my whole night, I can look closer at the spots where the guy actually has symptoms, the old dude gets better care, and the ER doc ultimately gets a faster turnover time.

Hmm, could you potentially send a med student on a rads elective to go down and get more information for you? As a student, I would do that. It's not really scut and it's a decent learning experience because you see the patient and then see his film being interpreted.

But yea, I see that your point was CYA medicine, which is bad for everyone.

 

[colbgw02]

Hmm, could you potentially send a med student on a rads elective to go down and get more information for you? As a student, I would do that. It's not really scut and it's a decent learning experience because you see the patient and then see his film being interpreted.

If we really think it's important, then we'll pick up the phone.



On a bit of a tangent, I have to share this conversation my upper level had with an intern the other day. It made me laugh out loud.

Intern: Hi, we need you guys to come put an NG (feeding) tube in this guy.
Rad resident: Oh, okay, you guys can't get it down?
Intern: Actually, we haven't tried yet.
Rads: Why don't you guys go ahead and try?
Intern: Because this guy really needs his tube feeds.
Rads: Well, I guess you better get started.
[Click]

We never heard back from them.

 

[f_w]

Rads: Well, I guess you better get started.

We never heard back from them.

As a fellow, whenever I used to get called for an IJ line, I told the intern that I want to see blood. A minimum of 5 puncture wounds had to be in the patients neck, otherwise I would send them back (horner syndrome, a juicy hematoma or a pneumothorax where accepted alternatives).

 

[sepsis]

On a bit of a tangent, I have to share this conversation my upper level had with an intern the other day. It made me laugh out loud.

Intern: Hi, we need you guys to come put an NG (feeding) tube in this guy.
Rad resident: Oh, okay, you guys can't get it down?
Intern: Actually, we haven't tried yet.
Rads: Why don't you guys go ahead and try?
Intern: Because this guy really needs his tube feeds.
Rads: Well, I guess you better get started.
[Click]

We never heard back from them.

LOVE IT:

having just been an intern I can relate.

On a saturday we had a resident (presumably an intern) who said she needed a dobhoff in a peds pt. They had tried before but couldn't get correct placement.

Now the kid we heard was a terror (the kicking, biting kind) , nevertheless, we said bring him down.

we are now done reading and wait for the kid to come down. 30 min passes and we call the floor, " sorry the nurse is too busy to bring the pt down, she'll bring as soon as she can". Of course the intern is no where to be seen. 30 min passes and the kid finally arrives, grumpy of course, and wants his mom who we can't get a hold of.

No biggie, then we notice that chart didn't come with the kid. 15 more min of waiting the chart comes with the intern and then, if can you believe it, there is NO consent. BUT, it' s all ok because the intern tells us that the 'other residents' said we didn't need one because she got verbal consent from the mom earlier in the morning.

at that point the attending, takes off his gloves, shrugs his shoulders and says 'OK then', the intern, confused, said 'so you're going to do it?' The attd says nope and I'm going home, try the tube and if it doesn't migrate by monday give us a call.

me, meanwhile, I'm snickering in a corner cause I get to go home too - I love rads.

not as fun as your story, but I'm so happy not to be doing medicine anymore 😀

 

[navigator420]

Hold on... no program has received a single application yet. I'd ignore any rumors about competition or anything else until the season is underway. Even those in the know (e.g. program directors) won't really know anything until ERAS opens, so hang on... we'll see what happens. At my program, competition has remained pretty tough, but we've pretty much hit a plateau in terms of number of applicants. We'll see how this year goes.

Hang in there,
doepug (pgy 4 / radiology)

now i am off the topic i guess , any way i hope you are right . boy, this application process is already getting on my nerves

 

[bosky]

Just a humble early R2 position....

It is hyperbole to say physical exam has been replaced by radiology, but there were often days last month where the Er would send me normal abdomen/pelvis CTs on the 64-CT because they didn't have a clue what was going on. I am not saying they were dumb, it's just the environment we live in now. e.g. yes, you learn to guess what a murmur is based on how the sound changes when they squat etc... especially for BS like Step 2 CS, but honestly, in PP if you hear something weird and don't get an echo, might as well call the lawyer.

Conversely, sometimes I see strange vague breaks in the cortical line or lucencies in the xray then call the ER physician and they tell me where the patient hurts - this prevents overcalls and often leads to calling occult/very subtle fractures.