We’re hiring!

Well, not me/this little site.

But my organically-growing 100%-independent physician-owned radiology practice of which I am a partner/shareholder is hiring in most subspecialties including breast, body, neuro, ER, and general. Basically everything except MSK and IR at the moment.

The market is hot, as I’m sure every radiologist and resident has heard.

I’ve written before about why I believe some job healthcare models are problematic, and why not all attending jobs are created equal. I’ve also written before about how to approach getting your first job out of training. My perspective and biases about radiology practice are on full display.

Our group was/is my first job out of training. I made partner last year and recently began serving on our board of directors. It was the job I wanted–so much so that the day I got the interview invitation email (after already having job offers waiting for a response), I did an actual Street Fighter dragon punch of victory and told the others they were going to have to wait past their response deadlines. I was drawn by two things:

  1. A well-established successful privademic model combining teaching-focused academics with the no-BS of private practice (with positions leaning more in different directions based on interest including pure no-teaching PP), which gave me the chance to teach and work with trainees in a more flexible environment than a traditional big academic bureaucracy. I’m currently the associate program director for our residency, and our residents are awesome.
  2. A sustainable job model combining high-quality (as opposed to only high-volume) radiology practice with reasonable daily expectations and the goal of a standard 4-day workweek (today is my day off!). I wanted the time and mental space to also be a partner at home and have the flexibility to do the other things that are important to me (like this). My colleagues are good at what we do, and I learn from them every day.

So if you’re in the market, come work with me and check out our great team in Dallas. If you’re interested, send me your CV at ben.white@americanrad.com and I’ll make sure it gets where it needs to go.

You Should Be Correlating Clinically

While I generally like to stay away from absolutely prescriptive advice, I think most radiologists would agree that the phrase “correlate clinically” is basically a microaggression against clinicians. It’s a trigger phrase and common joke that automatically lowers your work in the eyes of the reader. If somebody must correlate, then they should be told what they should correlate with: direct inspection, physical exam, CBC, a possible history of X symptom, sign, or disease, etc.

A new radiology resident typically begins training without much meaningful radiology experience but with substantial clinical knowledge. Don’t give it up. Of course, you will likely not stay up-to-date with every specific medical therapy used to treat the diseases you used to manage as an intern, but good radiologists retain a significant fraction of the pathophysiology that underlies the imaging manifestations of the diseases we train to discern and then supplements that foundation with a growing understanding of subspecialized management. That combination informs their approach in creating actionable reports for referring clinicians, reports that contain more of the things they care about and fewer that they don’t.

In the world of outpatient radiology, it’s common for patient histories to be lackluster. Frequently the only available information from the ordering provider is the diagnosis code(s) used to justify insurance reimbursement. In many cases, radiologists rely more on a few words provided by the patient directly (filtered through the technologist that performs the imaging study). We don’t always have the context we need to do our best work. It’s as frustrating as it is unavoidable.

In the more inpatient (or academic medical center) world that dominates residency training, it’s common to see at first glance a similar diagnosis code or short “reason for exam” text from the EMR, frequently limited in length and sometimes further limited to specific indications in the name of appropriate use (e.g. “head trauma, mod-severe, peds 0-18y”).

As a young radiologist, it is in your best interest to not rely on so thin a justification as what is readily dropped into the report via a Powerscribe merge field if you have access to richer information. You may know very little radiology, but you remain literate. You will do yourself and your patients a favor by supplementing your nascent diagnostic acumen with a real history obtained from reading actual notes written by actual humans. So often the provided “reason for exam” is willfully incomplete or frankly deliberately misleading, like the patient with acute-onset left hemiparesis resulting in a ground-level fall arriving with a history of “head trauma” instead of stroke. Or pretty much everyone with a history of “altered mental status.” So often, the clinical correlation was there all along. It’s part of the learning process that helps make the most of your limited training time.

“You can’t see what you’re not looking for” is a classic adage for a reason. You sometimes have to know the real history–as much as realistically feasible–in order to either make the finding or to put them into context.

So, before you ask anyone else to “correlate clinically,” maybe see if you can do it yourself.

Working for Private Equity: A Radiologist’s Experience

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

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

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 line anatomy up 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.