Approaching the Radiology R1 Year

There’s always a tension between giving specific advice (that doesn’t generalize well across different programs) and broad advice (that can sometimes be almost meaningless), but with that caveat, here are some thoughts about starting radiology training:

What to Learn

Anatomy

When starting out, it’s helpful to split your pursuit of knowledge into two big categories: anatomy and common path/aunt minnies. It’s actually pretty easy to go through your early months in radiology doing a passable job on your first visit to each section just by paying attention and looking for abnormalities without really hammering down on the anatomy. Symmetry helps. A background of low attenuation fat in the abdomen makes many findings more conspicuous, and the intrinsic high contrast of most lung pathology helps too. No one really expects that much of an R1, and by the time they expect more, you move on to another fresh start.

As you advance through your training, however, lack of anatomy knowledge becomes a bigger and bigger problem (especially as ultimately you need to be better than the clinicians who are increasingly comfortable looking at their scans if you want to add value, and many surgeons care about anatomy you can’t even directly see). Many folks basically give R1s a pass, and then those same people assume that upper-level residents already know the “basics,” meaning that many residents really start trying to learn radiology at a high level for the first time during Core review.

So taking time to really learn anatomy is important, because the worst time to realize you don’t know it well enough is the time you get embarrassed by something you clearly should have known. Hammering anatomy is something you’re going to have to do and redo over and over again until it sticks, then refresh again every so often. It’s very easy to forget, and search patterns atrophy quickly. You’ll find yourself memorizing and re-memorizing liver segments and lymph node stations and the spaces of the suprahyoid neck over and over and over again.

For example, when it comes to neuroanatomy, you might be able to squeeze by your first month doing CTs knowing the lobes, basal ganglia, big ventricles and major cisterns, big bones, etc. But at some point, you’re really going to want to sit down and learn some important functional surface anatomy, the medial temporal structures, all of the cranial nerves and their courses, everything that’s identifiable on a midline sagittal image etc. If that subtle finding that could easily be artifact would perfectly explain the patient’s symptoms, that could make all the difference! And don’t even get me started on the temporal bone.

Pathology

For foundational pathology, I would personally want to know the things I’ll see routinely (which are in books but also typically show up during daily service work) and the things that may be a bit silly but are pathognomonic (often referred to as “Aunt Minnies” in radiology). Top 3 Differentials and Aunt Minnie’s Atlas are great for this highest-yield case review and don’t take too long to go through for each rotation, allowing you to at least have heard of/seen some of these, giving you a foundation for when you see it again in conference etc.

Motivation

All-modality independent call is a fantastic motivator for pushing yourself during your first year. Conversely, doing month after month of just plain films can crush your motivation, and having an attending to read out with at all hours of the night will remove all of that inspirational anxiety.

If your program doesn’t have independent call, you’re going to need to find internal motivation. Going through scrollable unknown cases like CaseStacks can be helpful to both prepare for call as well as to simulate call. You don’t want to wait for dedicated Core Exam prep to really sit down and try to learn radiology for the first time. You also don’t want to feel like the first time you’re really able to “make the call” for tough cases is when you have no choice as an attending. That’s the fastest way to spend your first few years in practice hedging things for no reason and being generally unhelpful. A developing surgeon doesn’t go straight from retracting to operating alone; there is an extended period of graded responsibility. Many programs are offering less and less of this, which places the burden of personal growth squarely on the resident’s shoulders.

Ideally, you want to have a game plan and schedule to keep yourself honest for each rotation (maybe even specifically for the transition to each rotation). Over the short term, there is no external motivation to take your training seriously outside of the fear of looking stupid. Unlike having Step 1 or multiple shelf exams to worry about, the ACR in-service is a lame exam that few programs care about. Since essentially everything a resident does on the diagnostic side of radiology will go through a faculty before making its way to a clinician, fears about hurting somebody are primarily about hurting somebody in the future, when what you say actually matters.

Transitioning to becoming a radiologist is an unusual situation. During your internship, you likely found yourself getting more and more confident in your ability to provide clinical care. In many cases, you may have worked to some extent autonomously, especially at night.

An R1 radiology resident usually has no autonomy. Unlike clinical medicine, where you have clerkships as a strong foundation to build from, the new radiology resident has no foundation and is essentially starting from scratch. This is a weird sensation, stepping backward for the first time in your steady annual progress through medical training and becoming totally incompetent. I found it disconcerting.

Preparing for rotations

It would be ideal to spend a few hours before the start of a new rotation doing some light reading to shore up your background. This could be accomplished by reading the relevant chapter out of Core Radiology, for example, as well as other volumes such as the Fundamentals of Body CT for chest or belly CT rotations or Felson‘s for chest radiography. I would be lying to you, however, if I suggested that I had done this sort of pre-reading routinely.

With the exception of July, you should be able to tell from your fellow residents what the “day 1” expectations are. In most cases, you’ll probably be able to skate by for at least a few days without embarrassing yourself badly. In some programs, first-years still review cases concurrently with an attending and essentially transcribe reports by taking notes and then trying to re-create what the attending said. A more modern take is to dictate and type while the attending talks, essentially awkwardly repeating what they say like an unreliable parrot. Depending on staff style, a trainee could go through an entire rotation and never really have their fund of knowledge called into question. (It should almost go without saying that I don’t think this is an appropriate way to teach radiology.)

Being useful

With rare exceptions for technologically illiterate staff, the first-year resident on most diagnostic rotations isn’t going to save most attendings very much time on the clinical workload. The big exceptions are fluoroscopy, which is tedious, and any procedural service that requires consents and notage. Ultimately, being useful on these services is a function of the rotation itself, and since the trainee has no control over the workload on a service like fluoro, being useful in this regard amounts to just doing your job (working “hard,” having a good attitude, etc). So don’t be lazy. But for most DR rotations, it unequivocally takes longer to teach somebody imaging and work with them on the report than it does to just dictate the study yourself.

While I‘m sure each program is its own unique delicate flower and functions differently, two generally important tasks are answering the phone and protocoling studies. Being proactive, efficient, and reliable in your more secretarial roles is sadly one of the most noteworthy things a junior resident can do in radiology.

There is, unfortunately, a double-edged sword component to these tasks, as they are in fact rare situations for you to directly impact patient care by answering technologist or clinician questions. If you are especially cautious and ask tons of questions, you’ll be kinda annoying. But unless you are especially cautious, you are also likely to answer incorrectly at some point and upset someone. I think that’s unavoidable. Just learn from it.

The other really important thing is knowing the clinical history of cases you preview before reviewing with an attending, especially for cross-sectional studies and anything that looks weird. Reviewing the medical record makes a big difference in approaching complex studies and takes time. If you can tell faculty the medical, surgical, and treatment histories, you’ll have made things undoubtedly easier, and—unlike your radiology eye—your ability to synthesize clinical context is fully intact. There are few things more irritating than a resident who has previewed a cross-sectional study for half an hour but only knows the history of “abdominal pain.”

Oh, and proofread your reports.

Lastly, be on time

If you are supposed to start at 8 AM, be there by 8 AM. If you are supposed to start at 7:30 AM, be there by 7:30 AM. If you have a conference, then be there on time. Being late is the fastest way to stand out from your peers.