Category Archives: Figure Stuff Out

Thoughts and observations about everything in the kitchen sink from the meaning of life to deep-fried sushi.

More Important Than Doing Well

My wife and I take a routine monthly trip to Costco to refill the refrigerator. Now with less than two months from core exam, she said she can drive by herself so I can have more time to study. It was thoughtful of her to offer. I thought for a moment. Buying chicken and cheese may be routine and unexciting, but it is something we do together, and there are some things more important than doing well on a test.

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Doing Better Stems from Being Bored of Doing Good Enough

“The result of our approach,is that we end up with a team of people who will quickly become bored by performing tasks by hand and have the skill set necessary to write software to replace their previously manual work.”

Ben Sloss, Google

Google engineers are not afraid of automating themselves out of a job.  They embrace the challenge of finding the next best thing in machine learning, in big data, in medicine, or moonshots like longevity, because of this philosophy.

Are we bored with clicking and measuring things by hand yet?  Spell checking your report manually for semantic (i.e. error of meaning not spelling) errors? Making a differential diagnosis strictly from memory?  We should get bored.  Then we can start to improve it.

It’s when we are satisfied from “good enough” that we forget “doing better” is possible.

Programmable DNA Circuits Make Smart Cells a Reality – Sort of

… and imagine if you could program life itself.  Rather than 0’s and 1’s, you have four possibilities, a computing system performing quaternary arithmetics.

I still remember being dazzled as a freshman in college, during the first computer science lecture. The professor spoke of quantum computers, where improvements in speed of calculations can be measured in squaring time 2n rather than the traditional doubling time (i.e. Moore’s law) 2n.  And there was biologic computing, using simple building blocks of genetic material ACTG to perform calculations which take place in living cells.

Then, I spent the 15 years that follows writing them off as science fiction, pontifications of an old man.

I was, of course, wrong.

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The Value of Knowing What Lies Ahead

When I was in 8th grade, my English teacher wanted to give everyone a book to take into high school.  She had a cardboard box full of various books. There was literary fiction like Toni Morrison.  There was a memory aid for American presidents. But I came to class really late that day, so by the time I went up to the box, there were only a few books left.  I had the great choice between Billy Budd (dryest. book. ever.), Atlas Shrugged, and this book called Getting Things Done.

I picked up Getting Things Done because Atlas Shrugged didn’t fit in my bookbag.   It would be years before I realized that self-help productivity books is in itself a major genre of nonfiction.  At the time it just didn’t make sense why anyone would need such pathologic level of compulsion to keep things organized.

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Sway – The Way to Share Radiology Content in Web 3.0?

I stumbled upon Sway today.  Microsoft Sway promises to make creating web presentations easy, which is a fairly big claim.

I also happened to be studying MSK for the Core Exam, so I made a Sway approaches to mass lesions in bone. There will also be some comments on Sway.

Here’s the disclaimer: I am not an MSK expert, just some guy studying for the Core Exam!  Also, all images here belong to their original owners, not me.

Also, Sway’s navigation is a hybrid between ​PPT slide show and web-based scrolling. It takes a little getting-used-to.  Definitely try it in full screen, but it can also be embedded in a web page like this.

All in all, I was impressed with Sway, and I hope it continues to mature.

It did crash twice on me, but no content was lost as the app continuously saves your edits to the cloud the same way we have come to expect web apps.  Sway is the easiest way to create engaging content by removing the guesswork in design layout.  Whereas PowerPoint seems to encourage you to create bulleted lists after bulleted lists,  Sway encourages you to get your point across through pictures and videos.

I really like the direction the software is taking because this is how radiology content should be shared.

For someone who always needs to be doing something to keep focusing on the topic at hand, Sway kept me on task by providing an immersive environment for creating content. That’s always a plus.

Thinking of Snow

A friend did me a favor yesterday without being asked.  I asked him why.

He said earlier this week his neighbor decided to shovel snow for the entire block. The neighbor dug out everyone’s cars from several feet of deep snow.

The cynical might endorse The Chain of Screaming, but the opposite is equally true.  In the aftermath of the most severe blizzard the northeast has seen in recent years comes a warm act of kindness.

Cynicism and kindness are both contagious.  Which one will you spread?

The Best Time to Be A Radiologist   

Radiology is probably the most exciting field of medicine to be in right now.

Yes – reimbursements are less generous.
Yes – volume is paradoxically increasing, and we are busier than ever.
Yes – you spend most of your time away from patients.

Physicians are inherent scientists. We observe a pattern and draw a line of extrapolation. We do this subconsciously and assign value to these insights. If reimbursement decreased by 10% from last year, in 12 years we will be left with 35% what we started with!  However, we now know drawing lines using historical data requires a nuanced approach.

The best time to get involved in a profession as a young professional is at a time of rapid change. History records only times of conflict, of artistic or cultural debate, of Renaissance, the industrial revolution, and the digital age. Change is the enemy of stability and favors the adaptable. Change gives rise to new ideas and new efforts. Change is why Silicon Valley start-ups rise and fall with the ticking clock but yet remain some of the most exciting careers in today’s America.

It is in the midst of fluctuation, not stability, that we find the most fulfilling career opportunities. Radiology doesn’t guarantee success – your medical training did that for you. Radiology offers an environment to be creative precisely because so much of its future is in the air rather than in stone carvings.

So will you seize the unique opportunity and guide the flow of an entire medical discipline at a time of your life when you are best suited for it? If you have always been fascinated by medical imaging, now is the time to jump in.

You Don’t Have to Outrun The Bear

I had a wonderful discussion with an old friend from college who was trying to learn more about radiology. A computer scientist classically trained in a top US university for software engineering, she has years of experience in data science. She is now trying to apply her extensive expertise in analytics to healthcare. In our discussion, she began to express her concerns – having taken only 1 introductory biology course in college, she was worried that her limited knowledge in healthcare and medicine will prove to be the lynchpin of this transition.

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Complexity of Communication in Diagnostic Radiology

In diagnostic radiology, information is the currency. Although the clinical knowledge in diagnostic radiology is the most salient component, information in radiology comes in many forms. What is the most appropriate next step in diagnosis? What is the most appropriate way to explain the clinical impact of this incidentally noted, indeterminate adrenal nodule? How to describe this finding in the most understandable way now that our patients are reading our reports?

Image Credit: Larson et al, AJR, Figure 2

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The “Why” Question

When applying to residency, and perhaps to no one’s surprise, I always wanted to be asked during interview, “Why do you want to be a radiologist?” The “Why” question was an easy one to answer. After all, there was plenty to love about radiology – the challenge of solving a clinical diagnostic dilemma, the impact of catching an unsuspected Pancoast tumor, the satisfaction of revascularizing precious cerebral pneumbra. A better qualified medical student than I could discuss her scientific breakthrough, global health endeavor, and political leadership.

Change can unsettle even the best-prepared residents.

As medical students, we loved radiology for all the right reasons and wanted to talk about them. However, my generation of radiology trainees, the medical students who so eagerly entered this profession now grow concerned.

Indeed, my upper class colleagues were among the first to experience the radiology core exam. They were the first to experience the fourth year clinical concentration. They were the first to finish training not as board-certified radiologists, but board eligible. The changes do not end with training. No, the world we graduate residency into is brimming with uncertainty. My generation of radiologists will face evolving hiring trends, increasingly impersonal workflow, and dwindling Medicare reimbursement rates. We will be frontline soldiers in the ongoing battle between on-site radiologists and evolving teleradiology practices. We will comprise the proud new face of our profession, tasked to prove its value.

Change can unsettle even the best-prepared residents. I attended a recent Philadelphia Roentgen Ray Society meeting on the impact of the new American Board of Radiology examination changes followed by a panel discussion. Trainees and established radiologists filled the room, the air thick with uncertainty. I sat in the audience trying to absorb all the changes in the new ABR examination, the curricular changes in the final year of radiology, and the rippling effects they may have on the hiring process. Dazzled, I wondered how a modern radiology resident could expect to succeed when the metrics of success is a moving target. Eager for fresh air, I walked around the city before returning home.

Treading the paved urban sidewalk that evening, I walked past one of the new high-rise apartments in the city. When I began residency training three years ago, it was a construction site, little more than a steel frame wrapped in concrete. A year later, the building stood tall with large glass window panes, its lobby furnished with chiseled marble and glistening tiles. A little further to the east, a fresh construction site broke ground, born from the husk of an old store. Nascent city-sponsored self- service bicycle renting eased busy traffic, and pedestrians hurried past taxicabs in favor of rides hailed from the Internet.

Trainees who joined the profession looking for opportunities to improve care quality will find external change the best platform to introduce innovation.

Our world changes by the day, and it brings a nervous energy that is equal parts uncertainty and excitement. Practice change occurs at all levels in radiology, often for the better. Increasing awareness of radiation exposure in the public brought dose reduction techniques and dual energy systems into the forefront of CT research. The evolving reimbursement patterns fueled the American College of Radiology’s increasing emphasis on value-based imaging. Trainees who joined the profession looking for opportunities to improve care quality will find external change the best platform to introduce innovation.

Finally, some changes are frightening and some exciting, but parts of radiology simply have not changed at all. During a night shift several months ago a neurology resident asked me to review a head CT. The ordering provider did not see an abnormality but, “just wanted to be sure.” On a careful second perusal, a thin sheet of dense material revealed to be layering hemorrhage in the left middle cranial fossa, subtle but unmistakable when viewed from proper projection. The patient received close follow- up and the expanding hematoma expediently managed overnight.

The fulfillment of peering into a clinical problem to make an impact on a person’s life is a constant in radiology. In fact, so are most of those good answers that had compelled us to choose this profession in the first place. Perhaps therein lies the importance of asking ourselves the “Why” question. During this lengthy and rewarding training process, our answers to, “Why did I want to be a radiologist?” too will change. These answers form the compass as we wade through new uncharted waters. They give us the courage to sail ahead knowing the right direction, ready to tackle the thundering clouds that loom ahead.

I would not have a career any other way.

This post originally appeared in the January, 2015 Pennsylvania Radiology Society Newsletter.