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Working for Private Equity: A Radiologist’s Experience

07.25.22 // Radiology

This is part three in a series of posts about private equity in radiology. The first was this essay. The second was an interview with former PE analyst and current independent radiologist Dr. Kurt Schoppe.

This third entry is a Q&A with a radiologist who recently left a PE-owned practice and their experience as someone who joined a freshly purchased practice, made “partner,” and then left anyway.

I suspect this radiologist’s experience is very generalizable, but regardless it’s a rare and interesting perspective to hear, especially regarding their equity/stock holdings. The person providing their perspective will remain anonymous, and I’m also not interested in naming and shaming the group. This is intended to share a novel viewpoint and be helpful for trainees (and maybe also be interesting to spectators):

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Sigh-RADS

07.18.22 // Radiology

This is a work in progress, but I humbly submit a draft proposal for a new multimodality standardized radiology grading schema: Sigh-RADS.

Sigh-RADS 1: Unwarranted & unremarkable

Sigh-RADS 2: Irrelevant incidental finding to be buried deep in the body of the report

Sigh-RADS 3: Incidental finding requiring nonemergent outpatient follow-up (e.g. pancreatic cystic lesion)

Sigh-RADS 4: Off-target clinically significant management-changing finding by sheer chance.

Sigh-RADS 5: Even broken clocks are correct twice a day (e.g. PE actually present on a CTA of the pulmonary arteries).

Sigh-RADS 6: Known malignancy staged/restaged STAT from the ED

 

Update (h/t @eliebalesh):

Sigh-RADS 0: Inappropriate and/or technically non-diagnostic exam for the stated clinical indication.

Radiology Call Tips

07.06.22 // Radiology

It’s July, and that means a new generation starting radiology call. I’m not sure I’ve ever done a listicle or top ten, so here are fifteen.

The Images

  1. Look at the priors. For CTs of the spine, that may be CTs of the chest/abdomen/pelvis, PET scans, or *gasp* even radiographs.
  2. Look at all reformats available to you. On a CT head, for example, that means looking at the midline sagittal on every CT head (especially the sella, clivus, and cerebellar tonsils) as well as clearing the vertex on every coronal.
  3. Become a master of manipulation. If your PACS has the ability to generate multiplanar reformats or MIPS, don’t just rely on what the tech sends as a dedicated series. Your goal is to make the findings, and you should be facile with the software enough to adjust the images to help you make efficient confident decisions, such as adjusting the axials to deal with spinal curvature or tweaking images to align the anatomy to the usual planes when a patient is tilted in the scanner. MPRs are your tool to fight against confusing cases of volume averaging.

Reporting

  1. Your reports are a reflection of you. I don’t know if your program has standard templates or if those templates have pre-filled verbiage or just blank fields.  There is nothing I’ve seen radiologists bicker about more than the “right” way to dictate. What is clear is that you should seriously try to avoid errors, which include dictation/transcription errors as well as leaving in false standard verbiage. We are all fallible, and Powerscribe is a tool. Do whatever it takes to have as close to error-free reports as humanely possible.
  2. Seriously, please proofread that impression. Especially for mistakingly missing words like no.
  3. Templates and macros are powerful, useful, and easily abused tools, just like dot phrases and copy-forward in Epic. I am all for using every tool you have, but you need to use them in a way that comports with your psychology and doesn’t make you cut corners or include inadvertently incorrect information.
  4. Dictate efficiently. If you are saying the same thing over and over again, it should be a macro. If you use PowerScribe, you can highlight that magical text and say “macro that” to create a new macro. (On a related note, “macro” is a shorter trigger word than “Powerscribe”.)
  5. More words ≠ more caring/thoughtful. As Mark Twain famously said, “I didn’t have time to write a short letter, so I wrote a long one instead.” It’s easier to word vomit than to dictate thoughtfully, but no one wants to read a long (or disorganized) report. Thorough is good, but verbose doesn’t mean thorough. It usually means unfiltered stream of consciousness. The more you write, the less they read.
  6. Never forget why you’re working. The purpose of the radiology report is to create the right frame of mind for the reader. Our job is to translate context/pretest probability (history/indication) and images (findings) into a summary that guides management (impression).
  7. Address the clinical question. This is especially true in the impression. If your template for CTAs was designed for stroke cases and says some variation of “No stenosis,” that impression would be inappropriate for a trauma case looking for vascular injury.
  8. Include a real history. Yes, there are cases where an autogenerated indication from the EMR is appropriate, but there are many more where that history is either insufficient or frankly misleading/untrue. You need to check the EMR on every case for the real history. Then, including a few words of that history is both the right thing to do and also very helpful for the attending who is overreading you.

Your Mindset

  1. Radiologists practice Bayesian statistics every day. This is to say: context matters. A subtle questionable finding that would perfectly explain the clinical situation or be more likely given the history should be given more psychological weight in your decision-making process than if it would be completely irrelevant to the presentation. For example, a sorta dense basilar artery is a very different finding in someone acutely locked-in than somebody with a bad episode of a chronic headache.
  2. Work on your tired moves. We can’t all make Herculean calls at 4 am. When you’re exhausted and depleted, you rely on the skills you’ve overtrained to not require exceptional effort. For radiologists, this boils down to your search pattern. You need to not just have well-developed search patterns but also to have sets of knee-jerk associations and mental checklists of findings to confirm/exclude in different scenarios to prevent satisfaction of search (e.g whenever you see mastoid opacification in a trauma case, you will make sure to look carefully for a temporal bone fracture).
  3. Everyone is a person. The patients, the clinicians, the technologists, and any other faceless person you talk to on the phone. It’s easy to feel distanced and disrespected sitting in your institution’s dungeon. But even you will feel better after a hard night’s work when you’re a good version of yourself and not just someone sighing loudly and picking fights with strangers.
  4. Music modulates the mood.

A lopsided fig

06.24.22 // Miscellany

Jason Kottke, a true OG blogger, on taking a sabbatical:

Does what I do here make a difference in other people’s lives? In my life? Is this still scratching the creative itch that it used to? And if not, what needs to change? Where does kottke.org end and Jason begin? Who am I without my work? Is the validation I get from the site healthy? Is having to be active on social media healthy? Is having to read the horrible news every day healthy? What else could I be doing here? What could I be doing somewhere else? What good is a blog without a thriving community of other blogs? I’ve tried thinking about these and many other questions while continuing my work here, but I haven’t made much progress; I need time away to gain perspective.

I love good curation. With my two young kids, personal wants and need, and professional demands, I don’t personally have the bandwidth to really produce a filter+share site myself, but I really appreciate when someone can steadily put a high-quality narrative or personal spin on *waves hands vaguely in the air* all of this.

Kottke is an excellent blogger, and he’s been doing it since 1998.

Explanations for the 2020-2022 Official Step 2 CK Practice Questions

06.13.22 // Medicine

Update: The March 2021 pdf is identical outside of some minor formatting changes.

Update: The April 2022 pdf also seems to be unchanged.

The NBME released a completely new set of questions in March 2020, which was the first major update since basically 2015.

The 2019 set, which is completely different, is available and explained here for more free questions!

These are in the order of the PDF linked above.

 

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Should You Care About the ACR’s DXIT Exam?

06.08.22 // Radiology

Who & What

The Diagnostic Radiology In-Training (DXIT) is radiology’s in-service/in-training exam and it’s typically taken by R1, R2, and R3 residents midway through the year. Every(?) specialty has one.

It’s important to note that the ACR (the American College of Radiology) offers the DXIT exam, whereas the ABR (the American Board of Radiology) controls the longer multiple-choice nightmare that is initial board certification in the form of the Core and Certifying exams. These are different organizations that exist for different purposes that just happen to both provide multiple-choice tests for radiologists. The DXIT is one of many things the ACR does. Torturing you with their exams is literally all the ABR exists to do. The ACR is a democratic deliberative body. The ABR is not. They also don’t necessarily see eye to eye on the topic of certification.

Does the DXIT matter?

In the strictest sense, the DXIT simply does not matter. The ACR has no control over your future. The ACGME requires programs to perform a “summative assessment,” and the DIXT simply fulfills that need.

DXIT performance only matters if your program thinks it matters. There are no inherent consequences, good or bad, for your performance. Whether or not you get a high five or put into a remediation plan or just receive an email with your scores is up to your program.

It’s my anecdotal impression that most program directors don’t care all that much about the DXIT. If you get 95th percentile, you’ll probably get a pat on the pack? I know my program used to give out an award every year to the resident with the highest score. (The only awards available to non-senior residents were the highest in-service exam score and the research award. Perhaps a very narrow set of behaviors to promote and recognize, but that’s just my take.)

So if you are wondering if it “matters” for you, the answer is probably not: Statistically, most people are not going to perform at the extremes, and even programs that do care are likely to care most about poor performance. All things being equal, programs would obviously prefer their residents perform better than average (and our residents certainly do by a large margin).

But if you’re somewhere in the middle of the pack (i.e. ~50th percentile), I suspect it won’t really matter for you in your program unless otherwise specified. Every group has an average. If your program thinks you need to be at the 70th percentile or some other arbitrary floor in order to not get dissed in your semiannual review, then they should tell you.

Interpreting performance

One of the key limitations in interpreting in-training performance is this: did you study? Presumably, one key factor influencing how much you study is how big of a deal your program makes about the in-service exam. Therefore, residents in those programs may study more and outperform their national peers. Is this meaningful in the real world? Probably not? How does one compare the real-world performance of a resident who studies for two weeks and achieves 70th percentile and one who doesn’t study and gets 50th? I have no idea. High performance without dedicated review and low performance despite preparation are probably substantially more meaningful—but the test isn’t designed for any of that. It’s just a summative assessment.

However, if you are below average, and particularly if you fall in the bottom quintile, I would take the results more seriously. I want to be clear that such a score doesn’t mean you are a bad radiologist or a bad resident or that you do bad work. These are knowledge-based assessments that include a broad and idiosyncratic swath of radiology concepts. These tests are a poor proxy for real-world competence. However, standing between you-as-you-stand-now and you-the-independent-practitioner-of-radiology is a longer and more arduous exam that is the DXIT’s spiritual cousin. This is a wake-up call that you need to start or change the process you’re using to learn radiology. Either you need to up your radiology book learning earlier and/or begin the serious incorporation of high-quality questions into your regular review (e.g. if you haven’t been using your program’s RadPrimer subscription, then start).

Why it really matters

So, I would argue the real reason the DXIT matters, if at all, is as a predictor of Core Exam passage and therefore a possible wake-up call that your personal status quo may not be sufficient.

The reality is that the passage rate for the Core Exam is around 10-15% and that everyone will study much, much more for the Core Exam than they do for the in-service exam. Therefore, the conclusion that people in the bottom quintile of the DXIT are at substantially higher risk of Core Exam failure is highly intuitive. The Core Exam isn’t curved, but logically it’s not a stretch to imagine that the people performing the worst on one radiology multiple-choice exam might also be the same group that would perform worst on another radiology multiple-choice exam.

It’s obviously not perfect, but it’s probably the best thing we have access to at the moment.

There’s some data to back this up, and there are a few relatively recent papers that cover this:

  • Predictors for Failing the American Board of Radiology Core Examination
  • Predictors of Success on the ABR Core Examination
  • The Relationship Between ACR Diagnostic Radiology In-Training Examination Scores and ABR Core Examination Outcome and Performance: A Multi-Institutional Study

From the first paper:

This chart is from the first paper. Despite a relatively thick confidence interval, their conclusion was that “residents with scores below 20th percentile should be concerned.”

From the second paper:

In our study, higher percentile performance on the ACR ITE strongly predicted success on the Core Examination (P = .003322). [This was based on survey results where the average percentile of the passing group n=251 was 58th and of the failing group n=19 was 33.2th.]

Residents should see the ACR ITE as a crucial step in their training and adequately prepare for it.

From the third paper:

DXIT and Core outcome data were available for 446 residents. The Core examination failure rate for the lowest quintile R1, R2, and R3 DXIT scores was 20.3%, 34.2%, and 38.0%, respectively. Core performance improved with higher R3 DXIT quintiles. Only 2 of 229 residents with R3 DXIT score ≥ 50th percentile failed the Core examination, with both failing residents having R2 DXIT scores in the lowest quintile.

Interestingly, in both studies that tracked multiyear DXIT performance, the relationship between DXIT and Core performance was stronger for R1 and R3 residents and statistically insignificant for R2 residents. Why might that be? If anything, one might assume that the R1 performance would be the least useful given that many R1 residents are taking the exam before taking many of the relevant rotations. (For example, I hadn’t had body CT, ultrasound, mammo, or peds, to name a few). Perhaps the R1 results more reflect generic test-taking acumen, the R3 results partially capture early Core prep, and the R2 results are garbage because everyone is too tired from joining the call pool to bother preparing. Or perhaps the data is just messy garbage. Who knows?

Some possible takeaways

Fact: The statistical trends above are not destiny. It is information. What you choose to do with it is up to you.

If you feel like you studied for the DXIT but still performed in the lowest (or perhaps second lowest) quintile, then you need to look at your study methods. There’s a concept in educational literature that testing is learning. If you aren’t regularly testing yourself (e.g. question banks, flashcards), you are missing an opportunity for effective active learning as well as an important tool in the fight against the forgetting curve. Learning to practice radiology at the workstation and learning to master radiology testing are related but ultimately different tasks.

If you destroyed it, particularly as an R3, then your odds of failing the Core Exam probably approach zero (not that you are ready without studying per se (although maybe!?), but rather that with reasonable preparation you should be able to succeed by a clear margin (especially now that conditioning physics is no longer possible).

Resources

Unlike the ABR, the ACR is not so precious with its questions. Every year they release the test and its answers. See ‘previous exam sets’ on their In-Training Exam page.

For the flashcard fans among you, someone collected all those kindly released in-service exam questions from 2002-2021 into a big DXIT Anki deck, which in addition to being an extremely efficient DXIT review is also essentially a free high-quality almost ~2500 question Core Exam qbank.

The ACR also made a slew of question-containing ebooks for Continuous Professional Improvement (CPI) free during the pandemic, and those are still available for download. The files are all ebooks (.epub), so you’ll need an e-reader app (e.g. Apple Books) to view them.

You should also at some point read the ACR Contrast Manual.

Take home

I wish we had better predictive tools/exams for radiology that trainees could use during dedicated prep time to predict Core Exam passage like the score estimation available for the USMLE exams. We don’t. For every person that fails the Core Exam, there are also probably two who wildly overprepare.

Even though its interpretation is a little muddy, the DXIT is the best we have for now. It can give you a blurry snapshot of where you are versus where you likely want/need to be.

Studying for Third Year NBME Shelf Exams

05.11.22 // Medicine

[The original version of this newly updated/revised post was first published way back on August 19, 2012.]

Chances are, your third-year clerkship grades will hinge more on your NBME Shelf exam scores than on your clinical evaluations. The strategy I advocate is to come off of Step 1 strong by immediately shelling out for the UWorld Step 2 question bank for the entire year. Do the questions for each rotation.1And by do them, I mean do all of them while carefully reading the explanations. Mark all questions you guess on or get wrong and do those again. Rinse and repeat. Take your shelf exams, nervously wait 1-3 weeks for your scores to come back, and soldier on. Then at the end of third year, reset it so you can start fresh and use it to study for Step 2 CK. If you’ve studied for and done well on your shelf exams, UW and Wikipedia should basically be sufficient for Step 2 CK, which for at least the near future will be an extremely important non-pass/fail exam. The best way to perform well on Step 2 CK is to also prepare for and do well on your shelf exams.

While UW is, I believe, indispensable for several of the shelf exams, it is not sufficient. (Related: If you’re in the market for an additional question source, I do have some qbank discounts on the support page.) There are also a variety of online-based curriculum replacements that one can use for longitudinal learning during third year. But for book people, here’s how I would approach each clerkship:

 

Psychiatry

First Aid for the Psychiatry Clerkship is your must-read. It’s extremely quick, readable, and hits everything. You can read this book in a day if you want to; it’s that short.

The only book you would need after FA is Case Files Psychiatry. It’s a good volume in the series, and some of the cases do a nice job of distinguishing between adjustment disorder in its many forms (recognizing adjustment disorder versus MDD, GAD, acute stress disorder, and PTSD etc is extremely important for the psychiatry shelf). You don’t need more reading beyond that, just UW. Enjoy the psycation.

More than any other shelf, the psychiatry shelf really stresses adverse effects of its medications. Every important drug has its one or two, and you need to know them cold. All of them.

You also need to pay special attention to medical disorders with psychiatric manifestations (depression and pancreatic cancer, Addison’s disease; pheochromocytoma or carcinoid tumors masquerading as panic disorder; etc).

 

Ob/Gyn

Case Files Obstetrics and Gynecology is your first book of the rotation. When in doubt, you can always get through a Case Files book quickly and know that it will hit the highlights (i.e. common board/pimping questions). It’s an excellent foundation for your rotation, and you should read it as fast as possible.

Many people advocate Blueprints Obstetrics and Gynecology, as it is quite readable and nearly exhaustive. I would caution you that unless your rotation has light hours, many many students don’t have enough time or energy to slog through it. Many of my peers who started with Blueprints never finished a single book before taking the exam. They just didn’t have time. Finishing a single book is the most important thing; you need to have one cohesive point of view. Even Case Files alone is better than 3/4 of Blueprints. Don’t get yourself in trouble. Most OBGYN clerkships are exhausting.

If your school pays for the ACOG/APGO question bank, great. Definitely use it. If not, I’d just read Case Files again and do UW. Always focus on things that might seem similar and be able to tell them apart (placenta previa vs vasa previa vs abruption). You may benefit from a qbank supplement (or even PreTest) if you have time and no APGO access.

 

Pediatrics

Blueprints Pediatrics is the common favorite (and my wife’s personal favorite as well), and though I personally don’t care for the series, it is certainly sufficient. First Aid is overkill. Case Files Pediatrics (my favorite), patient reading, and UW for me was enough, but if you have the time and drive to read a more thorough text, I think BRS Pediatrics is actually the best.

As far as entries in the series go, Pediatrics PreTest is one of the better ones, and if you need more questions in book format, then it would be a reasonable use of your time (I personally wouldn’t bother).

You probably need two sources. Blueprints or BRS + Case Files is a common combination, if you can stand the cardiology section of BP.

Don’t go overboard on vaccine schedules and developmental milestones. You can sink a lot of time into that for little to no benefit. You should know a couple of big milestones per age group. Know the contraindications for vaccines; don’t learn the actual timelines.

 

Surgery

As always, crank through Case Files Surgery as fast you can so you don’t look like an idiot. Crush Step 2 / Step 2 Secrets (essentially the same book in different formats, one of which you’ll probably want/have anyway, I prefer the former) can also help you get a rapid-fire overview of surgery in less than a night (and is also a particularly nice way to quickly learn the very basics of the many surgical subspecialties, which are fair game on the shelf). However, the single best rapid review text is actually Dr. Pestana’s Surgery Notes, written by a now-retired faculty from the University of Texas Health Science Center at San Antonio. For years before the official version, a more informal packet was widely used and beloved by students around the world for being extremely quick and extremely high yield (you can find copies of that old standby pdf online).

Then, before slamming into UWorld with all your might, I’ve classically recommended the NMS Surgery Casebook. This dense book has been an essential read for the clerkship: excellent, organized well, good diagrams, and contains everything you need to know. Note, this is not the NMS Surgery textbook. Don’t bother with that thing. The Casebook is the better resource by far. In recent years, many institutions and students have recommended the newer Surgery: A Case Based Clinical Review, which is also excellent. They are analogous, so just pick one. After that, just do questions. Pay special attention to trauma management, which makes up a lot of the test. Many questions hinge on applying the ABCs properly, often comically obviating the need to know definitive management. If you would do two things simultaneously in real life, never forget that one of them technically comes first based on the ABCs.

Many students use Surgical Recall to help prep for pimping and an overall understanding of the day-to-day business of surgery. Surgery Recall is a good book for reviewing the common questions you are likely to receive/knowledge you need to succeed in-person and on the wards/in the OR. It’s a good book to carry in your white coat and pull out when you have a few minutes of downtime. I would not, however, rely on Recall as a primary studying guide when it comes to the shelf. Details about actual surgeries are not on the exam, but the management of surgical patients is. The portions that do apply to the shelf though are full of rapid-fire high-yield facts.

 

Internal Medicine

The best way to study for IM is to do all of UW Medicine. This will take several weeks but will be worth it. The second most important thing you can do is pay attention on the wards.

The favorite medicine text nationwide is Step-Up to Medicine, which is the best (and the third edition just came out). It’s a bit long, and you may find yourself dropping it in favor of getting through the question bank. Case Files Internal Medicine is decent (helpful mostly if your background is poor and because it’s shorter). First Aid isn’t worth your time. For practical knowledge on the wards, huge swaths of students swear by Pocket Medicine (formerly “the green book,” it’s been changing colors with each edition), though I personally think UpToDate is more interesting and more complete when a computer is nearby.

If you finish UW, do more UW. Nothing else comes close to being what you need.

 

Family Medicine

I leave Family Medicine for last because it’s one of the more irritating tests to study for. Take it later in the year, and it will be mostly straightforward. Taking it toward the beginning of your clerkships can make it the hardest test of the year given its broad scope and the handful of seemingly random questions on every test. If you have the choice, doing it toward the end of third year makes the test far more reasonable.

Medical students can become members of the AAFP for free and then use the AAFP question bank. I thought these questions were more resident-level than the real thing and didn’t love them, but they are undeniably a solid resource. You can slog through a ton of UW and that would work, but that’s a daunting task for a shorter rotation. To historically prepare via UW, you would ideally get through the OB, Peds, IM, and preventative sections. That’s a lot. UW recently began offering shelf mode, which includes family medicine, so at least that makes the prospect approachable, but this selection is still more tailored than you’d get from months of organic review. Definitely hit up UVA’s free online mini-qbank, which has 125 high-yield questions.

In the beginning of the year, Case Files Family Medicine would help give you the basics. Later in the year, it will likely just remind you of things you already know quite well. The ambulatory section of Step Up to Medicine is certainly a good idea. Some people use Blueprints FM (breadth but not depth) or Step 2 CK review books (try Crush Step 2, if you must). There just isn’t a great resource geared for the clerkship. That said, some students swear by the use of Swanson’s Family Medicine Review, which is written for the FM boards but has a nice case-based question-heavy format that would likely serve you well. If that seems too daunting, reading the pediatrics and ob/gyn sections of Crush Step 2 will at least help you rapidly hit the highlights.

In the end, family medicine is not a discrete field; it’s a combination of everything else: mostly medicine, a good helping of peds and ob/gyn, and even a bit of psych, surgery, and EM thrown in. My advice is to schedule it for later in the year, especially after medicine, which makes it much more manageable.

Questions, questions, questions.

Elective and sub-I book recommendations are here. Some thoughts on how to approach irritating/difficult clinical science questions can be found toward the bottom of this page. Step 2 resources are detailed here.

Looking for information on the preclinical shelf exams?
Anatomy, physiology, biochemistry, and microbiology are here.
Pathology is here.

The Truth about Private Equity and Radiology with Dr. Kurt Schoppe

05.09.22 // Medicine, Radiology

Have you ever talked to someone above you on the food chain—usually with the word manager, director, or Vice President somewhere in their job title—and after they depart, you just stared blankly into the distance while slowly shaking your head thinking, Wow, they really don’t get it. What a useless bag of skin?

Well, that’s the opposite of my friend Dr. Kurt Schoppe, a radiologist on the board of directors at (my friendly local competitor) Radiology Associates of North Texas and payment policy guru for the American College of Radiology where he works on that fun zero-sum game of CMS reimbursement as part of the RUC. He’s whip-smart and has a unique perspective: Before pursuing medicine, Dr. Schoppe was a private equity analyst.

Consider this transcribed interview a follow-up to my essay about private equity in medicine published a few months ago.

Here’s our (lightly edited conversation):

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Recommended Books for Radiology Residents

05.02.22 // Medicine, Radiology

[This updated/revised article was originally published way back on December 21, 2013]

There are lots and lots of radiology books out there.

Rather than list oodles of options, I’ve made a short editorial selection for each section. There are obviously many good books, but your book fund is probably not infinite and you need to start somewhere.

First-year residents, in addition to Brant and Helms Core Radiology, might start with these recommendations prior to buying any additional texts that they are unlikely to read at length during their first exposure to each section.

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Recommended Reading for First-year Radiology Residents

04.29.22 // Medicine, Radiology

[This updated/revised article was originally published way back on December 12, 2013]

Expectations for first radiology residents include a whole lot of reading. Tons and tons of reading. The follow-through on that expectation may be somewhat less impressive, but you’ll still do your best to pretend. Given the dizzying array of options, a curated list of book recommendations seemed like a good idea.

With your limited resources, as an R1 I recommend first buying the general books that will serve you well throughout the year (and beyond). If you still have more funds, you can figure out what to buy next based on your interests and needs (and this list) after you’ve read what you’ve got. At that point, your program’s library (and/or unofficial digital library) will be a good place to see what’s worth your money. You’ll be doing a lot of your reading for free online anyway.

Last Updated April 2022. Since I initially wrote this list, I’ve also added an additional post on Approaching the Radiology R1 Year.

General goodness

The quintessential Brant and Helms’ Fundamentals of Diagnostic Radiology was historically gifted by many programs. Find out if your program still does so before buying your own copy.

The huge single edition looks better on a bookshelf but is cumbersome. It’s too heavy to carry in a bag and honestly too heavy to sit in your lap. Get the 4-volume edition if you actually want to use it. I owned the single edition, and as a result, I only really used the online access. And, to be frank, while B&H may be the classic introductory text, it’s overrated and definitely not uniformly good throughout. Too much text with too few pictures, often overwhelming for the junior resident. If your program doesn’t use it, I probably wouldn’t bother.

Core Radiology: A Visual Approach to Diagnostic Imaging is the “new” monograph (first published in 2013, its title shamelessly taking advantage of CORE exam dread and a pattern subsequently used in many radiology books since). It’s a better introductory approach than B&H for new residents (or those at the beginning of board review). It was finally revised for a second edition in September 2021, so it’s fresh. Bullet points, shorter paragraphs, bigger font, more diagrams, and (an initially) single authorship with tailored content mean that this volume presents a coherent and more practical approach than the old standby.

Aunt Minnie’s Atlas and Imaging-Specific Diagnosis is a fantastic quick read. It’s organized by section with a collection of classic “Aunt Minnie” cases that you must learn because they’re common or classic fodder for conferences and the like. Each section is short so you can spend an evening or two reading it at the start of a rotation.

Top 3 Differentials in Radiology is another quick, excellent general book. While Brant and Helms may have been the quintessential introductory text, textbooks don’t necessarily serve as the best introduction to day-to-day work. Each page presents a single finding (e.g. solitary pulmonary nodule), the most likely diagnoses with brief descriptions, and a few pearls.

The text that concisely supplies the radiology facts (but not the images) was classically the Primer of Diagnostic Imaging (the “purple book” aka “First Aid” for radiology), which has lists, outlines, and diagrams galore. It was historically well-liked but has the potential to cause death by bullet point (personally not my cup of tea), and I’d argue Core Radiology now handles this task better overall. A slightly cheaper, question-and-answer formatted alternative is Radiology Secrets Plus. In my opinion, these two volumes are more of historical interest and can be safely skipped.

One step up in terms of detail from Top 3 Differentials is Clinical Imaging: An Atlas of Differential Diagnosis, which is organized by a pattern recognition approach. It’s a huge, atlas-like book, which you may or may not be that interested in reading.

So, in my opinion, Core Radiology, Aunt Minnie’s, and Top 3 Differentials are three things I would buy at the very beginning, as they’ll serve you well throughout the year.

Some people like to start with textbooks. Others prefer cases. I think there is something to be said for cases and classic findings, which give you a sense of familiarity with the subject prior to digging into a dry textbook chapter. For every rotation, you could go over your atlas to get a grip on the anatomy, then follow it with the relevant sections of Top 3 Differentials and Aunt Minnie’s, and the combination wouldn’t take more than a few days.

Most books focus on pathology and rarely provide a practical approach for how to review studies in real life (i.e. how to develop a search pattern). It’s something people slowly figure out on their own or try to derive from attendings. One adjunct some might find useful for approaching different exam types is Search Pattern.

Anatomy

You can use a variety of free online atlases and tutorials as early anatomy resources:  UVA’s  Introduction to Radiology, Radiology Masterclass’s CT Brain anatomy, the very cool RAAViewer software, HeadNeckBrainSpine (RIP), FreitasRad’s Musculoskeletal MRI, Stanford’s MSK MRI, CaseStacks, Learning Neuroradiology, etc etc.

Good dead tree atlases include Fleckenstein’s Anatomy in Diagnostic Imaging (on the pricey side) and Imaging Atlas of Human Anatomy (on the affordable side, and well worth it for someone who wants a paper atlas). Sectional Anatomy for Imaging Professionals is more of an anatomy textbook, with descriptions, diagrams, and selected cross-sectional images.

The most useful overall is IMAIOS’ e-Anatomy, which is an excellent website and app available as an annual subscription. If your program doesn’t buy you access, you should come together as a residency and request it. Radiopaedia has supplanted StatDX in a lot of use-cases, but e-Anatomy is pretty clutch (though still painfully detailed in some situations and yet wimpy in others).

Physics

Physics may be essential for the boards (and life), but understanding MRI physics is the subset most likely to help you both interpret studies, troubleshoot technical challenges, and understand pathophysiology. Learning MR physics early will help you make the most of your MR rotations (if your program relegates you to reading plain films for your first nine months, then nevermind). My favorite introduction is the Duke Review of MRI Principles, which is surprisingly affordable for a radiology book and a must-buy content-wise. It’s quick and case-based.

Another fantastic MR physics book for the non-physics crowd is MRI made easy (well almost), which is old but relevant, out of print, impossible to buy, and very easy to download online. For the rest of physics, the cheap book is Huda’s Review of Radiologic Physics (Bushberg’s costs more and says more than you probably want to know; I’m not sure anyone reads it anymore in the era of the Core exam). You don’t necessarily need either. The RSNA modules are fine content-wise, but the online flash design/format is truly horrible and painful to behold.

Sectional

What books you should supplement with on each rotation will depend both on what rotations you have during your first year and how much reading you actually get done. A more complete list can be found here, but here are a couple of guaranteed hits:

On chest, Felson’s Principles of Chest Roentgenology is what you need to read for plain films. For cross-sectional chest/body, Fundamentals of Body CT is a more portable and readable replacement for Brant and Helms.

Call-Readiness

A new resource (as of April 2020) that I think is super neat is CaseStacks, a new subscription service that puts a ton of high-yield bread and butter cases with actual DICOM images and a serviceable web-based PACS that lets you actually experience real scrollable pathology as you do in real life (and not just an image or two as in most question banks). Each case also has findings (often including ancillary findings, like real life) and a pretty solid sample report, which will help you see practical examples of how to put some words on the page. I would absolutely have done this as a first-year or early second-year before taking call. (If my program had a subscription, I’d probably try to knock out the relevant cases first thing during the rotations like neuro CT as well.) As per my usual affiliate MO, I reached out and was able to secure you 15% off with the code benwhite.

What should I read as an intern to prepare for radiology?

Nothing. You can go in blind and not look particularly stupid.

That said, you can often pick up old books for ridiculously cheap if you want to get a headstart. Most of it won’t stick without having the volume of daily reading and dictation to put it into context.

A more useful book to read as an intern (any intern for that matter) is Felson’s, which is the book for plain film chest interpretation. Everyone should know how to do this. As a bonus, you may get to see how full of it some of your senior residents and attendings are “who read all of their own films.” Save the big book-buying for when you have a book fund to burn through.

If you’re really interested, you can hammer home some anatomy and familiarize yourself with basic radiologic pathology online. The Radiology Assistant is a really nice concise resource for a wide variety of normal and pathology. Radiopaedia concisely explains a great number of topics and has become the true Wikipedia of radiology. You can also browse the web and watch online lectures. Most societies have oodles of resources and free membership for trainees.

Once you’re ready for further reading, here is my compilation of highest yield texts for residents broken down by section/modality.

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