one year into radiology, but still not loving it or any better at it

[alexagator]

I know a lot of people share similar sentiments about struggling and not loving radiology, having regrets during their first year. Others offer reassurance saying it gets better after that initial year. Well now that I’ve moved onto my 2nd year, I only feel worse about having chosen radiology.

I think the biggest problem is that I still feel (and likely I am) grossly incompetent and that radiology is innately too difficult for me. I struggle with catching all the abnormalities particularly on cross sectional imaging, and when there is an abnormality, I hem and haw over how to describe it. Then I need to look up the differential. It takes a lot of effort and at the end I’m still unsure about the accuracy of my report.

There are certain things that I’m super prone to missing, like lymph nodes, lung nodules, small aneurysms on head/neck CTAs, subtle fat stranding, dilated pulmonary artery, rib fractures, the list goes on and on. Also don’t get me started on the bowel. I can identify obstruction but finding the transition point…forget it. I do study outside of work, but I was never the best at memorizing and have to put in twice as much time to retain info than the average person. Having radiology knowledge is different than having the radiology “eye” and fluency in the vocabulary. Some people seem to have a strong sense of what is normal/abnormal but as an extremely indecisive person, I don’t think my “meter” is well-developed. I try my best to look at a lot of cases and read others’ reports, and there has been small improvement, but I still just don’t “get it”. My classmates all seem to be ahead of me.

This is all coming to a head as I am starting true independent call very very soon, and my poor performance will be revealed to all the attendings as they overread me the next day. So far I’ve “passed” because the attendings will point out my misses during read outs and I can edit my drafts to their liking before they sign off. Does anyone have advice on how I can improve my accuracy, speed, and my reports? Should I ask if I can postpone call? (but I don’t see how I can, there is no one to replace me for those shifts…) Or is this something that call will provide the experience for, accepting that I will inevitably have misses and less than perfect reports?

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[Tiger100]

There is not such thing as radiology eye.
Some people are faster and some people are slower. But radiology is all about experiece. There is no such thing as innate talent.

Some grandiose academic people want to picture themselves as gods but radiology and medicine is all about experience. Trial and error. Do it 100 times and you will do it well.

 

[Tiger100]

Call is not a board exam to postpone it. It is a place to learn.
If your program doesn't get it and has very high expectations, then change your program.

 

[2brads]

You need to realize that EVERYONE has misses. Everyone. From the chair of the dept at the ivory tower to the first year, first day resident. You will have a terrible time going forward if you are unwilling to accept this. Your goal is to try to keep the misses as small as possible.

 

[alexagator]

You need to realize that EVERYONE has misses. Everyone. From the chair of the dept at the ivory tower to the first year, first day resident. You will have a terrible time going forward if you are unwilling to accept this. Your goal is to try to keep the misses as small as possible.

I accept that I will always have misses, but I think I miss things at a higher frequency relative to my peers (gauged by case conferences, looking over other’s call cases/reports)

 

[Clean7795]

I know a lot of people share similar sentiments about struggling and not loving radiology, having regrets during their first year. Others offer reassurance saying it gets better after that initial year. Well now that I’ve moved onto my 2nd year, I only feel worse about having chosen radiology.

I think the biggest problem is that I still feel (and likely I am) grossly incompetent and that radiology is innately too difficult for me. I struggle with catching all the abnormalities particularly on cross sectional imaging, and when there is an abnormality, I hem and haw over how to describe it. Then I need to look up the differential. It takes a lot of effort and at the end I’m still unsure about the accuracy of my report.

There are certain things that I’m super prone to missing, like lymph nodes, lung nodules, small aneurysms on head/neck CTAs, subtle fat stranding, dilated pulmonary artery, rib fractures, the list goes on and on. Also don’t get me started on the bowel. I can identify obstruction but finding the transition point…forget it. I do study outside of work, but I was never the best at memorizing and have to put in twice as much time to retain info than the average person. Having radiology knowledge is different than having the radiology “eye” and fluency in the vocabulary. Some people seem to have a strong sense of what is normal/abnormal but as an extremely indecisive person, I don’t think my “meter” is well-developed. I try my best to look at a lot of cases and read others’ reports, and there has been small improvement, but I still just don’t “get it”. My classmates all seem to be ahead of me.

This is all coming to a head as I am starting true independent call very very soon, and my poor performance will be revealed to all the attendings as they overread me the next day. So far I’ve “passed” because the attendings will point out my misses during read outs and I can edit my drafts to their liking before they sign off. Does anyone have advice on how I can improve my accuracy, speed, and my reports? Should I ask if I can postpone call? (but I don’t see how I can, there is no one to replace me for those shifts…) Or is this something that call will provide the experience for, accepting that I will inevitably have misses and less than perfect reports?

You will likely improve significantly once you start call and you make higher stakes real time decisions.

1. Missing small details: This can be fixed with better templates. If you miss something add it into your template and look for it when you get to that point in the template. Once you've rectified it, remove it from the template.

2. Missing fat stranding: Will fix itself once you see enough cases.

3. Following bowel: This is 95% practice. If you've read a few of these cases and given up running the bowel, then you will never develop the skill. A lot of things in radiology you have to take time to work on in your own time.

4. Hem and hawing about descriptors: This shows you have not seen enough cases and/or have not read up on what's actually important. Descriptors in radiology correlate with some clinical/physiologic/prognostic significance.

I do think that some have a certain "talent" for radiology, but it more so comes down to having a strong broad base of clinical knowledge, knowing how to learn fast, personality that is not overly anxious, and a strong fortitude that can maintain high levels of disciplined concentration for long periods. Ultimately anyone who was capable of graduating medical school should be capable of becoming a radiologist. There is certainly a skill differential between rads, but once you pass the boards you should be capable of practicing safely with baseline competence.

 

[Smallfishtinypond]

I would suggest you to discuss this matter with your attendings in private. Try to get their perception of your ability. Get more than one attendings, to include the one that seems to know you most, the one that is most supportive and even the most asinine attending, in your opinion. Tell them to be frank. Your sincerity will be productive in receiving helpful suggestions. They know you more than anyone here. Good luck. We all struggle at one point in radiology, in one way or another.

 

[guytakingboards]

You need to realize that EVERYONE has misses. Everyone. From the chair of the dept at the ivory tower to the first year, first day resident. You will have a terrible time going forward if you are unwilling to accept this. Your goal is to try to keep the misses as small as possible.

This.

I accept that I will always have misses, but I think I miss things at a higher frequency relative to my peers (gauged by case conferences, looking over other’s call cases/reports)

The misses are there to teach you. You gotta learn from every miss. Refine your search pattern. Solidify your diagnostic certainty of xyz findings.

Radiology is absolutely one of those 10,000 hour skills. It takes a ton of reps to get decent at it and even then people still miss stuff.

Two more things:

1) Stop comparing yourself to your peers. Not sure if there's a degree of imposter syndrome going on, but in any event comparing yourself to your peers accomplishes nothing. The only time points that matter are the Core exam and attendinghood. You might be behind now and proceed to make huge leaps during your call year and jump ahead of your co-residents. Seen it before. It just doesn't matter how they're doing now.

2) For call, just avoid the 'can't miss' diagnoses. Everything else, it sucks if you miss it but it's not gonna be a game ender for someone.

 

[vm26]

I know a lot of people share similar sentiments about struggling and not loving radiology, having regrets during their first year. Others offer reassurance saying it gets better after that initial year. Well now that I’ve moved onto my 2nd year, I only feel worse about having chosen radiology.

I think the biggest problem is that I still feel (and likely I am) grossly incompetent and that radiology is innately too difficult for me. I struggle with catching all the abnormalities particularly on cross sectional imaging, and when there is an abnormality, I hem and haw over how to describe it. Then I need to look up the differential. It takes a lot of effort and at the end I’m still unsure about the accuracy of my report.

There are certain things that I’m super prone to missing, like lymph nodes, lung nodules, small aneurysms on head/neck CTAs, subtle fat stranding, dilated pulmonary artery, rib fractures, the list goes on and on. Also don’t get me started on the bowel. I can identify obstruction but finding the transition point…forget it. I do study outside of work, but I was never the best at memorizing and have to put in twice as much time to retain info than the average person. Having radiology knowledge is different than having the radiology “eye” and fluency in the vocabulary. Some people seem to have a strong sense of what is normal/abnormal but as an extremely indecisive person, I don’t think my “meter” is well-developed. I try my best to look at a lot of cases and read others’ reports, and there has been small improvement, but I still just don’t “get it”. My classmates all seem to be ahead of me.

This is all coming to a head as I am starting true independent call very very soon, and my poor performance will be revealed to all the attendings as they overread me the next day. So far I’ve “passed” because the attendings will point out my misses during read outs and I can edit my drafts to their liking before they sign off. Does anyone have advice on how I can improve my accuracy, speed, and my reports? Should I ask if I can postpone call? (but I don’t see how I can, there is no one to replace me for those shifts…) Or is this something that call will provide the experience for, accepting that I will inevitably have misses and less than perfect reports?

I'm about 10 years out with 2 fellowships under my belt. I'm in private practice in a moderate-sized "specialized" group and I am constantly challenged by case complexity (internet is a huge asset!), and humbled by misses. In hindsight, taking independent call with only 1 year training seems kinda crazy but it is what it is. Your job as a resident on call is to report significant findings (eg. findings that alter acute management). The other stuff may be important and one that you will be responsible for as an attending, but not as a trainee dictating prelims.

Drop the comparing mind-set. Learning curve for radiology (and other specialities I assume) is highly variable. Also have to keep in mind what your standard is (residency attending's). Residency training is really the bare-bones of the field these days. Here's a semi-bad analogy: you are essentially a freshman being exposed to senior+ standards. The reality is that some of the stuff we do requires much higher education/training/experience. Probably zero rads out there that can read all diagnostics (eg. OB US, MSK/body/neuro/breast MR, cardiac MR/CT/nukes, pediatrics, and mammo) while performing IR, and slinging barium....Like all fields in medicine, there are uncertainties and challenges. My biggest issue with PP radiology these days is the utter isolation (or peaceful solitude?), constant escalation of reading faster, and being in my head all day long. Aside from that it's a being good gig.

 

[LittleFoot]

You seem like you're hypersensitive to your own deficiencies. I can pretty much guarantee you that your coresidents are also missing many of the same things you are, in addition to other things. Keep going, it will get better.

 

[Rad2013]

For the SBO transition point… look for the small bowel loops that appear to contain stool rather than liquid. This often happens near the transition point and can help focus your search.

 

[letmebe]

I totally relate to OP. I do believe that some people have a better eye, and I think that’s partly because they enjoy the nature of the job. As an R2, I still have embarrassing misses. It’s hard to focus on every little blurry thing, especially on MRI. I get mental fatigue midway and this can make me miss or misinterpret things even if I see them.

@vm26 I couldn’t help but read your old posts back when you were a fellow. The thread where you were mentioning how you had trouble finding a job was pretty enlightening about this field. I wish I read it before I applied.

It’s unfortunate because I strongly think we will get back to the days of 2013 when you were mentioning how difficult the market is. We pump out close to 1.5k residents every year. There can’t be 1.5k unfilled jobs annually, just doesn’t make sense. I think the boom right now is very short-lived (2-3 yrs at most).

Back to the sweatshop.

 

[guytakingboards]

I totally relate to OP. I do believe that some people have a better eye, and I think that’s partly because they enjoy the nature of the job. As an R2, I still have embarrassing misses. It’s hard to focus on every little blurry thing, especially on MRI. I get mental fatigue midway and this can make me miss or misinterpret things even if I see them.

@vm26 I couldn’t help but read your old posts back when you were a fellow. The thread where you were mentioning how you had trouble finding a job was pretty enlightening about this field. I wish I read it before I applied.

It’s unfortunate because I strongly think we will get back to the days of 2013 when you were mentioning how difficult the market is. We pump out close to 1.5k residents every year. There can’t be 1.5k unfilled jobs annually, just doesn’t make sense. I think the boom right now is very short-lived (2-3 yrs at most).

Back to the sweatshop.

The only thing that's going to severely tighten the radiology labor market in the next 5 years is a workable AI solution. Otherwise the number of rads being produced is far under current demand and future growth. While 1500 unfilled jobs seems like a lot (and it is), residents don't really have a sense of how fast older rads are retiring AND how fast demand is going up. The net negative number of rads is only going to increase over the next 3-5 years.

 

[vm26]

I totally relate to OP. I do believe that some people have a better eye, and I think that’s partly because they enjoy the nature of the job. As an R2, I still have embarrassing misses. It’s hard to focus on every little blurry thing, especially on MRI. I get mental fatigue midway and this can make me miss or misinterpret things even if I see them.

@vm26 I couldn’t help but read your old posts back when you were a fellow. The thread where you were mentioning how you had trouble finding a job was pretty enlightening about this field. I wish I read it before I applied.

It’s unfortunate because I strongly think we will get back to the days of 2013 when you were mentioning how difficult the market is. We pump out close to 1.5k residents every year. There can’t be 1.5k unfilled jobs annually, just doesn’t make sense. I think the boom right now is very short-lived (2-3 yrs at most).

Back to the sweatshop.

That was a challenging time! If I recall correctly, I did not get an official offer/contract for my 1st job until memorial day weekend during my fellowship year. This contract was substantially "different" (sub-optimal) than the one discussed during my interview a few months earlier. It was a tough go in a lousy location. Def built some scar tissue/resilience from the experience.

Hard to predict how things play out in the future but right now things are pretty open for us. There are over 1600 jobs listed on the ACR site as of today. Granted many are not great jobs (private equity such as RP etc), but when I was a fellow there were like 200-400 jobs listed. Many boomers in rads are retiring and we as a field have been pretty conservative with residency expansion (as opposed to ED which seems like the field will be in bad shape for at least 10 years or so). Mid-levels can help us a bit with light IR/flouroscopy, but thats it (for now). Its pretty hard to recruit new rads these days and PP groups have been adapting (eg. more parity for telerad positions-not talking about nighthawk). If anything the severe shortage of rads if long-term can become a problem (eg. rationale to increase scope of practice to mid-levels).

 

[tomballunger]

Regarding not enjoying radiology, have you considered IR? there's always ESIR and IR fellowship, and sometimes depending on how many people in the class want to do it, getting into ESIR/IR fellowship might nowhere be as hard as matching stuff like ENT ortho uro neurosurg, assuming you do a reasonable job throughout DR and IR rotations. I know some people doing ESIR or the DR/IR direct track and they definitely seem to enjoy the clinical nature of IR more than being in the reading room doing DR compared to people going DR and DR fellowships

 

[Tiger100]

The only thing that's going to severely tighten the radiology labor market in the next 5 years is a workable AI solution. Otherwise the number of rads being produced is far under current demand and future growth. While 1500 unfilled jobs seems like a lot (and it is), residents don't really have a sense of how fast older rads are retiring AND how fast demand is going up. The net negative number of rads is only going to increase over the next 3-5 years.

Disagree.

The current fast pace of retiring has a lot to do with economic and social changes during Covid. It has almost already stopped.

This job market will be very short-lived, no more than 2 years. After that, things will go back to normal.

And to be honest, the job market is still not as good as 2000s. Lot of crappy jobs out there.


Don't forget that it takes almost a year for groups to hire a new associate. And it takes another year for the practice to reach some kind of stability with addition of the new associate.

I can see signs of slowing market even now. Many groups in my area have hired 2-3 people in the last year and don't have any plans to hire more in the foreseeble future.

 

[forchinet121]

I’m wandering over from another forum so I’m not familiar with radiology but am I understanding that year 2 residents are taking independent call meaning the ED sends them an image and they have to make the read of that image in real time and then report back to the ED doctor and this is all being done without any attending oversight? Or am I missing something? That seems crazy to me that someone with such little experience is going to influence surgery vs not, discharge vs not, etc. i hope someone reviews these images later?

 

[Neopolymath]

I’m wandering over from another forum so I’m not familiar with radiology but am I understanding that year 2 residents are taking independent call meaning the ED sends them an image and they have to make the read of that image in real time and then report back to the ED doctor and this is all being done without any attending oversight? Or am I missing something? That seems crazy to me that someone with such little experience is going to influence surgery vs not, discharge vs not, etc. i hope someone reviews these images later?

It is no more autonomy than good programs in other specialties that haven't been neutered provide.

The reports are over read in the morning.

 

[forchinet121]

It is no more autonomy than good programs in other specialties that haven't been neutered provide.

The reports are over read in the morning.

Is there a chief resident or someone as backup in case you get completely confused by an image?

 

[Clean7795]

I’m wandering over from another forum so I’m not familiar with radiology but am I understanding that year 2 residents are taking independent call meaning the ED sends them an image and they have to make the read of that image in real time and then report back to the ED doctor and this is all being done without any attending oversight? Or am I missing something? That seems crazy to me that someone with such little experience is going to influence surgery vs not, discharge vs not, etc. i hope someone reviews these images later?

What are you surprised about?

If you show up at a world-class academic hospital with an acute issue, after being seen by the ER doc you will have your imaging read by a radiology resident, clinically evaluated by a surgery or medical resident for admission and treated based on their assessment. Unless someone is doing surgery or an IR procedure on the patient, most of the care is managed by residents.

In PGY-1 on general surgery if I didn't call the surgeon in, then it meant I felt comfortable making the decision that the patient didn't need surgery and I could start initial management myself as an off-service resident. The entire general surgery ward and consults were my responsibility. It's not much of a stretch to imagine that a junior radiology resident is making calls that other physicians act on for admission, discharge, surgery, and other serious situations.

 

[forchinet121]

What are you surprised about?

If you show up at a world-class academic hospital with an acute issue, after being seen by the ER doc you will have your imaging read by a radiology resident, clinically evaluated by a surgery or medical resident for admission and treated based on their assessment. Unless someone is doing surgery or an IR procedure on the patient, most of the care is managed by residents.

In PGY-1 on general surgery if I didn't call the surgeon in, then it meant I felt comfortable making the decision that the patient didn't need surgery and I could start initial management myself as an off-service resident. The entire general surgery ward and consults were my responsibility. It's not much of a stretch to imagine that a junior radiology resident is making calls that other physicians act on for admission, discharge, surgery, and other serious situations.

In surgery you would have a senior resident that is in house with you was my experience

 

[guytakingboards]

Is there a chief resident or someone as backup in case you get completely confused by an image?

In the places that still have true independent call, there's usually an on-call attending or fellow available by pager. But it's impractical to call them often.

In surgery you would have a senior resident that is in house with you was my experience

That was the case maybe half of my surgery internship overnight rotations. A good number of overnight rotations, my lifeline was at home.

-Week of burn ICU nights: Me and an NP. Attending at home.
-Emergency General Surgery nights: me, a mid-level resident (who took the consults), NP and an attending on overnight.
-VA nights: just me. upper level/attending at home
-Community surgery rotation: just me. attending at home
-liver transplant nights: upper level at home.
-peds surg: me and a fellow asleep upstairs in the call room.

Granted if I really had a question I could reach out to an upper level on another surgery service, but otherwise it was calling the cavalry at home.

This kind of graded autonomy is still pretty common in other specialties as mentioned.

 

[MouseChair]

I am sure you are better at it than July pgy2. Just compare yourself to new r1s, you have come a long way