Student Loans Virtual Noon Conference

I gave a virtual noon conference today for MRI Online. It requires a free registration, but it’s one of a collection of great radiology lectures available for free. This is week 19 of the series.

My talk is permalinked here. It starts with discussing a brief history of student loans in the US as well as a pretty detailed discussion of PSLF including dispelling some myths including an explanation of the high rejection rate.

If you listen and notice me laughing at the beginning, that’s because my Zoom session crashed when I attempted to share my screen and I had to restart. Audio cuts out here and there but is nearly 100% intact, pretty good for a Zoom call. And if you listen to any of my podcasts or other talks this past year, you can safely assume I’m sleep deprived (babies are cute) compounded today as I ended up covering the early morning 6 am shift, but it definitely has some really some useful nuggets for those who like audio/video. It’s no substitute, however, for sitting down for a few hours and reading my ad-free totally-free book in whatever format you choose.

One participant asked a great question that I incompletely answered during the Q&A at the end. It was, essentially, what happens to student loan debt after a divorce in a community property state like Texas? The answer is that it usually goes back to the individual borrower, but, that’s only because all assets and debts that happen before the marriage remain individual property and revert back to the individual while all things that happen during the marriage are shared equally. Since most people in the US have just undergraduate loans and most people get married after college, most people won’t have to deal with their spouse’s loans after a divorce. But certainly not all, and this is more likely to be an issue for doctors, who may enter school married or get married while in school. Timing is everything.

Review: Orbit CME

It was always a good idea, but in this new world where conferences and live events are canceled for the foreseeable future, Orbit CME is a great idea.

(I previously got temporary free access to Orbit for the purposes of writing this review over a year ago, and I’ve got the usual reader discount affiliate link combo for you here: $20 off any plan. As there aren’t any ads here, these types of win-win situations for good products are one of the only ways I earn money through my writing. So there’s your COI disclosure.)

Orbit is a web browser plug-in that promises to automatically track and quantify the qualifying educational activities you do every day on your computer and then provide you with effortless legit AMA PRA Category 1 CME (often including the somewhat more challenging “self-assessment” SA-CME that some fields require that you typically get for answering questions during each lecture at a medical conference or other interactive activity).

How does it shape up?

Pretty darn well. In order to deliver the value of your subscription, you need to have the abilities/privileges to install the orbit browser plug-in (which is currently only available for Google Chrome). This plugin monitors your browsing and triggers whenever you visit a website that might come in handy for CME, like PubMed, Radiographics, or Radiopaedia. It measures your time with that active browser window, and generates an entry in your CME log. You can then choose which entries to actually spend a credit on to get the CME for it, in case you need certain types (like medical ethics in Texas or MQSA, Cardiac CT, fluoro, etc).

For example, while the hospital PCs only had internet explorer installed until recently, I had no problem using Chrome with the plugin when I worked at imaging centers or from home. As a radiologist, I earned CME so fast just from my usual day-to-day work that even if only using it on my home PC I would have been able to get the entire year’s worth of credits within a month or so, at which point I just uninstalled the plug-in.

Every once in a while I would have random difficulty logging into the plug-in (which does require logins periodically to make sure you’re still you), but otherwise, the process was completely seamless. CME is provided through Tufts, and you can download detailed CME logs for submission to various bodies that require such things.

You can also post external CME to the Orbit site allowing you to track all of your CME in one place and generate one report containing everything you’ve done. Very handy.

When I first discussed the product with the Orbit founding team back after finishing fellowship, I couldn’t help but feel that the price was too steep and thus not worth it ($360/yr for 25 credits; $600/2yr for 50 credits). But then I saw how truly effortless it was and how much a hassle the documentation burden of CME can be. If you enjoy conferences, it’ll always be possible to get enough CME through the activities you plan on pursuing anyway. If you’re in academics, you may acquire enough through your work activities like tumor boards and grand rounds to not need anything else.

But for those who don’t–and certainly in the current COVID world we live in where nothing is happening except remotely–I would rather pay to have my CME automatically generate itself than to do so via a virtual meeting (or some other laborious educational activity). I’ve got an infant and a preschooler, a busy practice, and a bunch of hobbies that are struggling for a minute of sunshine. I do CME every single day I work, and this gives me credit for that. Even if you get CME from other places like I do, there was something especially nice about not needing to bother tracking it down or keeping personal records because Orbit gives you everything you need anyway. If you have an academic/educational/CME fund, it’s definitely money well spent. It also works for PAs and NPs in addition to physicians.

The product was initially designed by a radiologist for radiologists, and it is absolutely perfectly suited to our workflow. But it also works well for many other specialties, and they have a handy table here telling you what kind of CME plugin can get you relative to the demands of your specialty society.

I’ll be subscribing again.


How to be a First Year Radiology Resident

This is a brief companion post to my original post on approaching the radiology R1 year. This is what you need to do to succeed in radiology and life:

Be a decent human being and use common sense.

If that’s not enough to go on, here’s a longer list:

  • Be on time
  • Be excited
  • Be nice
  • Be dressed
  • Take responsibility
  • Do what you’re told
  • Read cases, not just books. Be hungry.
  • But…um, also read books, not just cases. Practical knowledge is often different from book knowledge, but you’ll eventually need both to succeed
  • Be knowledgeable. If you can’t know radiology, then Know the Patients. Know the Histories. Know the Priors.
  • Again, always look at the priors and read the prior reports. Prior reports will teach you more than your attendings will face to face.
  • Proofread. Please, please, please. A report is a radiologist’s will manifested. Who do you want to be?
  • Anatomy is the foundation on which all else is built.
  • Develop a search pattern.

Real expectations for a first-year resident in July: are you ready?

In addition to the important life skills I outlined above, I want to stress that really no one expects you to actually understand radiology at this point, but you are expected to learn fast. What you can do—even on day one, even if you don’t actually know anything—is learn the details of the exams: especially patient history and priors. Look at this before you read out because this is literally your one chance to save your attending time and effort. A junior resident is graded more on attitude and attention to detail than on fund of knowledge.

Anyone who cares about what they’re doing can craft reports (almost) free of transcription errors, template mistakes, missing comparisons.

It’s not uncommon to hear from your chairman or program director during orientation that they want you to have a life and be well-rounded. Like, they’re not asking you to do anything crazy, just an hour or two of reading per night. If you were worried that a deep belly laugh might escape to your great embarrassment, then you are not alone. In an ideal world, you would read every night from textbooks and articles and then rapidly move onto writing your own and contributing to the great growing body of truly meaningful radiology research.

Well, sometimes life happens.

While I like knowing things and doing my job well, I wouldn’t have exactly described myself as a radiologist residency completionist. I didn’t necessarily read as much as some people suggested was prudent, and I’ve certainly never enjoyed and found meaning in trying to memorize long differentials for all the things that can occur in a given area when A) those differentials often include things that are radically different either clinically or by appearance and thus would never be confused and B) I have the ability to, you know, access the internet when I’m stumped by an unusual finding.

Keep in mind, this little list was generated from my own experience (in hindsight) and ruminations. The intrinsic variability across programs and training means that parts of my perspective may not or should not apply to you.

But I suspect if you do all of the above to start each of your rotations you’ll be on the right foot.

The ABR Comes Around

The American Board of Radiology announced earlier this week that they would indeed be joining the civilized medical world and moving to a virtual exam solution for all future exams and maintaining the current proposed February and June dates for next year’s administrations:

We appreciate the constructive feedback regarding our 2020 exam schedule and recognize the significant impact that test postponements have had on our candidates, their loved ones and families, and their training programs. We have seen and heard legitimate concerns from candidates, program directors, department chairs, and other stakeholders, and have considered many options to safely administer our exams in the least disruptive fashion while preserving their integrity. Our deliberations and decisions were largely based on our obligation to accommodate those most affected by the pandemic. The health of candidates, volunteers, staff, and the public is our highest priority. In consideration of these concerns, the ABR is moving all currently unscheduled and future oral and computer-based exams to virtual platforms beginning in the first half of 2021, which is the earliest we can confidently deliver these exams without potential delays.

Good for them.

Seriously, I mean that.


And I don’t want to be needlessly negative (or do I?), but as I argued back in April, have said multiple times since, and was then subsequently joined by the entire field of Radiology and its many member organizations, this outcome was the only defensible choice. Nationwide travel for an exam is simply an untenable position right now. Hell, doing so for a computerized test was barely defensible before the pandemic.

Despite all the hemming and hawing and the repeated stance that virtual solutions were simply “not practicable,” the ABR will be moving forward with one of those unpracticable solutions anyway in 2021. It was inevitable, which makes the drama and delay wholly unnecessary.

If the ABR had read the writing on the wall back in March when the world shut down, they still may have not been able to keep the original June date. But they likely could have salvaged the initial backup November date for which every residency program in the country already planned around. That date was closer to the usual timeline and was likely fairer for the senior residents, who will now be forced to re-study and potentially re-broaden their practice as they return from early IR specialization or mini fellowships.

Despite the ABR’s official stance, the Core Exam is not a test you could just pass on the merits of radiology skill alone. The evaluations practicing rads take, the Certifying Exam and OLA, are both easier.

On the one hand, good on the ABR for at least planning to do the right thing. I look forward to seeing how they decide to accomplish this mission, one they originally said they simply couldn’t do. There are a lot of self-imposed boxes to check because “the inability to adequately control image quality, the testing environment, and security would significantly threaten the fairness, reproducibility, validity, and reliability of the testing instrument across all candidates.”

So, on the other hand, the situation was ridiculous. There was a bonafide revolt before the ABR came around to what should have been an obvious choice in the first place. Now that we’re here, the move away from centralized testing should be permanent.

It goes to show that while the ABR has added responsiveness to its toolbox, they have not yet independently demonstrated sound stewardship of our field. Stakeholders need to be willing to fight for every important issue.

I hope this is a turning point for the ABR and its testing mandate. I know the radiology community stands ready to provide constructive dialogue to help improve initial certification and MOC.

Review: CaseStacks Radiology Call Prep

Before we get to it, the usual disclosure: this is not a paid review, but it is the usual kind where I get to offer a reader discount combined with an affiliate link, a win-win that makes it worth my time to write these reviews for products that I believe in. Coupon code benwhite gets you 15% off.

One of the most difficult things about radiology residency is the transition to call, especially for those programs that still have independent call. You go from generating draft reports that your attending may never read before just telling you what to say to suddenly being responsible for actual words that directly impact patient care. Compounding this stress is the fact that you may not have seen everything that you need to see during your rotations to prepare you for this experience. Reading books and articles and doing questions from casebooks or question banks are all certainly helpful, but they don’t simulate the process of actually opening a case on PACS, working through it, and mentally making a decision.

Enter CaseStacks, a new subscription site created by two Neuroradiology fellows at Wake Forest.

CaseStacks aims to be the way that radiology residents prepare for call.

CaseStack has multiple “courses” of different case types each with a combination of high-end bread and butter and some more complicated pathology, all presented with PACS simulation. Currently available courses are Neuro CT, Neuro MRI, Body CT, Chest CT, MSK Radiographs, Peds Radiographs, Chest Radiographs, and KUB. Several of these are subdivided. For example, Neuro CT includes Nontraumatic Brain, Traumatic Brain, Head & Neck, and Spine. Most also include a combination of “classic” and “practice” modules, the latter adding a combination of more subtle findings and negatives to keep you on your toes.

CaseStacks uses a web-based PACS, so all cross-sectional cases are scrollable, allowing you to really experience the case as you would in real life (can also window/level and zoom/pan). Each case is accompanied by findings, a diagnosis, teaching points, and a “preliminary report” that puts some real words on the page for how you might dictate the case in real life (very neat). Cases also include incidental findings that are invariably present in real life but never included in qbanks or casebooks, which typically only include a few static images and don’t reflect the breadth and variety of a real shift.

There are also 5 assessment modules, which include a combination of unknown cases including normal exams for a self-assessment (or for programs to test you) prior to taking call. This feature isn’t as fleshed out yet. The 5 offerings vary widely in length and do not combine all courses (or have a peds variant), so there is no single assessment that, say, covers neuro/body/chest CT + variety of radiographs. That would be clutch, but they’re not there yet.

The site technically works on mobile but doesn’t play that nicely. You’re better off with at least a laptop size screen.


They offer plans in 3-, 6- and 12-month increments for cross-sectional, plain film, or everything (“pro”). The pro version is $33.33/mo for a full year (~$400, pricey), and the price goes up to $45.33/mo for the shortest duration (3 months = $135.99). Definitely expensive but possibly a more practical use of your book fund than collecting books you probably won’t read.

Free Stuff

The free sample is a breath of fresh air. You can just navigate to the site, click on courses, and see a few complete cases from each class. No login required to see if it tickles your fancy.

Also free with no login required? Anatomy modules, incidental findings tables, normal head CT findings/variant/mimics (things all residents mistake for pathology at some point), peds radiographs normals by age (extremely helpful, especially for musculoskeletal radiographs). All 100% worth checking out and a great resource for call. Definitely bookmark it. I would have really loved the peds normals my first time taking solo peds call.


If CaseStacks existed when I was an R1 or R2, I absolutely would have paid for the service for a few months before starting call. It would’ve been invaluable for my confidence going into a challenging experience.