What makes a good radiologist?

[mikil100]

Hey guys, I've been trolling resident forums for a while as a naive first year who frankly doesn't know what he likes. We are currently doing or MSK section and learning a lot of anatomy. I find the anatomy enjoyable overall, but at times it does become tedious. Anyways, Rads is something that interested me, I do like looking at radiographs and trying to find the pathology, if there is any 😉, and a little mix of procedures and opportunity for IR is really appealing. Today I tried looking at some MRs of the GH joint and rotator cuff and it was completely disorienting to me. Honestly I could really only identify major land marks and had a hard time even orienting myself as to what direction/axis I was looking at.

I guess this gave me an appreciation for the difficulty of Rads but it also made me wonder if there is a certain..type of person that excels at it. I feel like because this content is super fresh I should be able to do well with it (also realizing I have no clue of what I do/don't know beyond the last 3 months of school).

I plan on shadowing a radiologist as soon as I learn a bit more anatomy to see if it's my thing, but any input now would be greatly appreciated! Thanks

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[Director1]

There's a great article on how to become a good first year radiology resident and beyond. Take a look at:

http://radsresident.com/2016/09/22/how-to-make-a-good-impression-as-a-first-year-radiology-resident/

Hey guys, I've been trolling resident forums for a while as a naive first year who frankly doesn't know what he likes. We are currently doing or MSK section and learning a lot of anatomy. I find the anatomy enjoyable overall, but at times it does become tedious. Anyways, Rads is something that interested me, I do like looking at radiographs and trying to find the pathology, if there is any 😉, and a little mix of procedures and opportunity for IR is really appealing. Today I tried looking at some MRs of the GH joint and rotator cuff and it was completely disorienting to me. Honestly I could really only identify major land marks and had a hard time even orienting myself as to what direction/axis I was looking at.

I guess this gave me an appreciation for the difficulty of Rads but it also made me wonder if there is a certain..type of person that excels at it. I feel like because this content is super fresh I should be able to do well with it (also realizing I have no clue of what I do/don't know beyond the last 3 months of school).

I plan on shadowing a radiologist as soon as I learn a bit more anatomy to see if it's my thing, but any input now would be greatly appreciated! Thanks

 

[meister]

Good knowledge of clinically relevant anatomy/pathology while not getting lost in the weeds of useless incidentals.

Knowing what to make a big deal out of and what to let go.

Not leaving a gigantic list for me to inherit on call.

 

[jazzman84]

Looking at anatomy on MRI is not the same as when you are in the gross lab. Especially in shoulder MR, the imaging planes can be confusing if you are not accustomed to it. I wouldn't let that discourage you from pursuing rads if you find the work interesting. Also, there are opportunities to be procedural in pretty much every facet of rads, not just IR (I say this as someone who was dead certain I wanted to do IR before residency but have now seen the light of the darkroom).

 

[FootballFoot]

Looking at anatomy on MRI is not the same as when you are in the gross lab. Especially in shoulder MR, the imaging planes can be confusing if you are not accustomed to it. I wouldn't let that discourage you from pursuing rads if you find the work interesting. Also, there are opportunities to be procedural in pretty much every facet of rads, not just IR (I say this as someone who was dead certain I wanted to do IR before residency but have now seen the light of the darkroom).

What made you change your mind about IR?

Do you think most positions in the future will primarily look for DR/IR combined candidates?

 

[Director1]

Radiology is a specialty where the resident needs to hone/fine tune his/her readings over time. A resident needs to train his eye by reading tens of thousands of studies. Many residents that were not so "good" as first years blossom into outstanding radiologists later during their Residency or in their career. Take the long road and read lots of books, sit with your attendings as much as possible and most residents will have the potential to succeed.

 

[WellWornLad]

Good judgement is usually what separates the good from poor radiologists. Clinicians tend to see imaging studies as some sort of black box that spits out absolute truths to be decoded by the radiologist in their own sweet time. The truth is that every diagnosis that can be made by imaging has a sensitivity and specificity, and finding that sweet spot on the ROC curve is the hardest part. Anyone can achieve close to 100% sensitivity, but you'll be the most hated radiologist in the hospital cause you'd have to overcall the vast majority of studies.

 

[qxrt]

Anyone can achieve close to 100% sensitivity, but you'll be the most hated radiologist in the hospital cause you'd have to overcall the vast majority of studies.

Particularly this! Learning the anatomy and recognizing abnormalities is basic level junior resident stuff. I have an attending who will call every single borderline thing that catches his eye with as vague wording as possible (e.g. "lung opacity" for a pulmonary nodule) and with as many hedge words as possible (e.g. "limited evaluation," "query"). Not only do I despise such reads and embarrassed to have my name associated with such useless reads, but several surgeons who have come to me on call have specifically mentioned that they hate this attending's hedging.

You do not need medical training to identify abnormal patterns or findings on a series of images. The physician part of radiology comes in deciding what is going to be clinically relevant versus what you shouldn't mention, and also trying to provide answers instead of trying to put the responsibility of diagnosis on the clinician by calling out every potential abnormality. Over-calling things has the potential to harm patients, too!

 

[deleted116380]

The best are the ones with succinct dictations, no hedging, and keep a clean worklist.

 

[Gadofosveset]

The best are the ones with succinct dictations, no hedging, and keep a clean worklist.

This describes both the best and the worst radiologists I've seen.

The best radiologist cares about getting the patient the right diagnosis, keeps his or her skill set up to date, and knows when to offer a differential and when not to.

 

[tco]

The best are the ones with succinct dictations, no hedging, and keep a clean worklist.

It's absolutely impossible to have "no hedging..." You can make your best conclusion followed by a differential, but there are times that you cannot be certain.

 

[deleted116380]

By "no hedging," I didn't mean giving one diagnosis and it being correct. Pathology exists because radiology is not able to make a diagnosis on imaging alone all the time. There are times radiologists hedge by adding too many useless differentials. Saying you can't exclude something that would be very odd in a patient with a known clinical history and exam helps no one.

 

[tco]

By "no hedging," I didn't mean giving one diagnosis and it being correct. Pathology exists because radiology is not able to make a diagnosis on imaging alone all the time. There are times radiologists hedge by adding too many useless differentials. Saying you can't exclude something that would be very odd in a patient with a known clinical history and exam helps no one.

Gotcha. Maybe I have a limited scope, but I don't know anyone who does that. Or if I do, I just have ignored it.

 

[deleted116380]

Gotcha. Maybe I have a limited scope, but I don't know anyone who does that. Or if I do, I just have ignored it.

Most in radiology probably don't notice since the clinical indication on prior reports given is something like "shortness of breath" or another very non-specific indication. If one takes just a little time in looking briefly at the patient chart, you can usually answer question based on the clinician's note. I've seen many many reports where differentials are given that are completely useless once one sees lab data, patient history, and even a brief physical exam that's documented. Some of the reports are dictated without looking up more information and others just list the same differentials to cover their bases even if they're aware of it (imo hedging).

 

[tco]

Most in radiology probably don't notice since the clinical indication on prior reports given is something like "shortness of breath" or another very non-specific indication. If one takes just a little time in looking briefly at the patient chart, you can usually answer question based on the clinician's note. I've seen many many reports where differentials are given that are completely useless once one sees lab data, patient history, and even a brief physical exam that's documented. Some of the reports are dictated without looking up more information and others just list the same differentials to cover their bases even if they're aware of it (imo hedging).

On the other hand, how hard is it to give a decent indication? If you're dictating 100 studies in a day and it takes you 3 minutes to look up a "brief history" on half of the patients...

 

[deleted116380]

On the other hand, how hard is it to give a decent indication? If you're dictating 100 studies in a day and it takes you 3 minutes to look up a "brief history" on half of the patients...

Depends how your system is setup. Our PACS has the EMR built-in so I click one button in IntelliSpace and it pulls up the chart with the medial problem list, allergies, and meds on the frontpage. Tabs at the top for pathology, labs, and clinician notes. It takes less than a minute to go through it all. There's no need to do it for every exam since not every exam requires a differential (normal ones don't nor do aunt minnies).

 

[tco]

Depends how your system is setup. Our PACS has the EMR built-in so I click one button in IntelliSpace and it pulls up the chart with the medial problem list, allergies, and meds on the frontpage. Tabs at the top for pathology, labs, and clinician notes. It takes less than a minute to go through it all. There's no need to do it for every exam since not every exam requires a differential (normal ones don't nor do aunt minnies).

That's why I said half. And yeah, as you said, not every system is set up that way. Two of our hospitals are, but one isn't.

 

[Director1]

A good easy to use electronic medical records system can really make or break a report since context is so important in the final differential diagnosis.

 

[cowme]

Cut the jargon and fluff. So many 3 page reports riddled with prose and stream of consciousness. What would you rather read as a clinician?

There is a 1.9 cm T2 hyper intense lesion in segment 8 of the liver, with peripheral nodular enhancement on late hepatic arterial phase and progressive centripetal enhancement on portal venous and equilibrium phase. The lesion does not exhibit washout or restricted diffusion and is most consistent with a hepatic cavernous hemangioma.

Or

1.9 cm hemangioma in segment 8.

when you call a clinician for more history, you don't want a medicine rounds-style 5 minute presentation. Get to the point and don't waste everyone's time with irrelevant nonsense

 

[tco]

Cut the jargon and fluff. So many 3 page reports riddled with prose and stream of consciousness. What would you rather read as a clinician?

There is a 1.9 cm T2 hyper intense lesion in segment 8 of the liver, with peripheral nodular enhancement on late hepatic arterial phase and progressive centripetal enhancement on portal venous and equilibrium phase. The lesion does not exhibit washout or restricted diffusion and is most consistent with a hepatic cavernous hemangioma.

Or

1.9 cm hemangioma in segment 8.

when you call a clinician for more history, you don't want a medicine rounds-style 5 minute presentation. Get to the point and don't waste everyone's time with irrelevant nonsense

Findings: See impression.

Impression: Blood in vessels or some $hit in some segment of that big organ on the right, top belly area.