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
- Look at the priors. For CTs of the spine, that may be CTs of the chest/abdomen/pelvis, PET scans, or *gasp* even radiographs.
- 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.
- 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
- 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.
- Seriously, please proofread that impression. Especially for mistakingly missing words like no.
- 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.
- 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”.)
- 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.
- 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).
- 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.
- 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
- 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.
- 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).
- 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.
- Music modulates the mood.
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.
(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 
is actually the best.
as fast you can so you don’t look like an idiot. 
/ 
(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 
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.
, 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. 
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 
(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.
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 
(breadth but not depth) or Step 2 CK review books (try 
, 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 
was historically gifted by many programs. Find out if your program still does so before buying your own copy.
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.
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 “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 
. In my opinion, these two volumes are more of historical interest and can be safely skipped.
, 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.
(on the pricey side) and 
(on the affordable side, and well worth it for someone who wants a paper atlas). 
is more of an anatomy textbook, with descriptions, diagrams, and selected cross-sectional images.
, which is surprisingly affordable for a radiology book and a must-buy content-wise. It’s quick and case-based.
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 
is a more portable and readable replacement for Brant and Helms.