Category Archives: Figure Stuff Out

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

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.

What Is the Radiology Personality?

What’s your radiology personality?

I recently ran into this thread on an online forum about an introverted medical student trying to choose a specialty. The thread referred to this book which contained a chapter declaring the “best-fit” specialty using Myers-Briggs Type Indicator (MBTI). The types including radiology are as follows:

  • ISTP – Otolaryngology (ENT), Anesthesiology, Radiology, Ophthalmology, General practice
  • ESTP – Orthopedic surgery, Dermatology, Family practice, Radiology, General surgery
  • ENFJ – Thoracic surgery, Dermatology, Psychiatry, Ophthalmology, Radiology
  • ENTP – Otolaryngology (ENT), Psychiatry, Radiology, Pediatrics, Pathology

In the comments section, one astute contributor promptly posted the following… Continue reading

The Bliss of Zero

The clock hit 7pm. My thumb off the deadman switch on the dictaphone. The glow of the reading room workstation monitors reflected off my glasses. I squinted. A click of the mouse. A curious pause.

And then there it was. I saw…

Nothing. A worklist with zero unread exam.

Inbox zero, Epic Radiant variant.

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A signature is our handwritten imprint on a document for authenticity.

A signature is also a unique identifier for what is distinctly us, like DNA and fingerprint.

Your work, too, deserves a signature. It deserves a sign of authenticity, and if you are proud of that work, mark it yours. If the quality of the work is not to your par, then don’t put it out.

Just as importantly, the work is itself a signature. Innovation is as much about doing something new as it is doing something you. An easy and sobering way to decide is to first write down all the components of a project onto a list. Then, strike away all the parts that could be accomplished by someone else. Your team will always solve those problems. But if nothing is left, then you have learned that the project doesn’t need you.

That which remains, then, is uniquely you. It’s your value-added. Your signature.

The Natural Progression of Radiology as A Business Practice

The terminal destination of all products and services is commoditization.  So that’s a simple answer, though one that’s not all that simple.  The management journal Harvard Business Review dedicates several classic articles on the process of commoditization, including global competition, process modularization, and, simply, the natural resting place of a mature product.

So where does radiology sit in the natural growth process?  More importantly – as junior residents – what have we gotten ourselves into?

Where is radiology in the natural growth progression?


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The Virtue of Being a Follower

One of my good friends – a respected colleague – once said, “I’m a follower, not leader.”

This (other) guy wrote a book on great followership (i.e. as opposed to leadership).

The first follower takes the courage to say, “Hey these people are onto something!”

The first follower is what makes a trend, just as the second point on a graph makes a line.

Being an expert follower is prerequisite for a good leader, and following is itself a form of leadership.

To all the followers out there, this list is for you:

  1. Thomas Jefferson, first a vice president, then president
  2. Barack Obama, first a senator under Clinton, then president
  3. Microsoft Windows, not the first GUI operating system
  4. Apple iPhone, not the first smartphone
  5. Facebook, not the first but the most successful social network
  6. Frodo, the second Baggins to bear the ring
  7. Jesse Pinkman, the sidekick you root for
  8. The Empire Strikes Back, the better follow-up movie.
  9. Pablo Picasso, a grand follower of classical realism before breaking free
  10. Twitter, a social network that celebrates the act following

So let us, too, celebrate followers.

How Do You Solve Your Maze?

Envision a mouse trying to solve a maze for a piece of cheese, and he has to decide which way to turn at the first cross-section. He takes a look at the three possible routes, thinks for a bit, then turns a sharp left and ran. In a complex labyrinth, the mouse would most likely reach a dead-end by blind guessing.

A regular mouse might get confused (where’s my cheese?!). A smart mouse might think “well that’s all wasted effort, let’s start over” and start again from the beginning. But a smarter mouse might try to backtrack as little as possible, by going back to the nearest intersection and making a different turn.

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Do Your Research Before Doing Your Research

Recently I had an idea.  Something just clicked when I least expected it – of course!  Why didn’t I ever thought of that before?  A simple research question.  A simple way to answer it.  Helpful contribution to knowledge.  I began to assemble the idea by writing it down, into outlines and paragraphs, thinking through all the possibilities.

Then it occurred to me to use PubMed.  It turns out that although I didn’t “ever thought of that before,” someone else clearly did.   It was a good paper.  So there was that.

Every now and then we all stumble upon an idea so good, so exciting, so cool that we want to pursue it and make it our life’s goal – a research focus, a project, a new company.

Just be careful that someone else might have had that epiphany too.  Last year. Find out what happened to that idea before starting yours.