What to look for in a radiology residency?

[thatchemguy]

Besides from the obvious such as a diverse caseload with interesting/complex pathologies, ability to moonlight, etc. what should I be looking for in a good radiology residency program? Currently finalizing my program list and wanted to know what things to help differentiate programs.

What do you wish you knew before applying? What type of call structure/night float is ideal? What amount of faculty:resident ratio? etc.

Thanks!

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[tomballunger]

Hospital communication system is important- ask if there's reading room assistants to help make those phone calls, or if not how easy is it to get in touch with primary teams- very easy to find the primary team and page them to relay critical findings at some programs, others, not so much. This is information best gleaned from private conversations with residents. Someone's always watching on zoom interview days and residents can't be totally honest.

Ask the residents how the program creates study time for R3s taking the core. Some will take them out of the call/er pool in the 2nd half of R3 put them on easy rotations.

At the end of the day though, regardless of program, radiology will always have a very steep learning curve for those starting out, possibly the steepest one in all of medicine (applies to IR Dr too since they take the core exam r3 and also spend 3 whole years doing diagnostic rads/studying)most radiology programs will provide all you need to become a great radiologist and pass boards- radprimer, crack the core books and vids, core radiology, board vitals statdx are all standard so anyone who can grind through all of these will pass boards and do fine in radiology.

Ask the residents if program provides all of this without extra cost because they are extremely expensive -statdx costs 2300 ish a year, crack the core and core books and vids another few hundred, radprimer 500. Most programs do provide these, but make sure since they are so expensive (even surgical loupes for the surgical sub residents aren't anywhere this expensive)

Job market in diagnostic rads insanely good currently, but all pretty much require very fast readers since almost all high paying postings expect people to read very high volume. Despite the IR hype, the vibes on job postings/forums feels like diagnostics is whats going to bring in money currently and near future. So even if interested in IR, don't neglect DR quality Obviously you don't get to see the day to day work of the residents through an interview but huge difference in capabilities/knowledge between R1s and R2s and even bigger difference between R1s and r3/4. Most R4s passed boards, matched fellowship and signed on or interview for jobs literally 2 years from their start date, they do their own thing, pick rotations they want, sometimes just work remote from home. R3s in early July are putting together fellowship apps (stuff like breast and msk seem to start very early)- so by end of r1- early r2 many people decide what they want

Faculty/resident ratio is important-too low and it means you won't learn as much when faculty have to split time amongst too many trainees. Programs might advertise a high ratio, but ask the residents how many trainees each faculty supervise on a given day-2 or fewer is ideal. But programs can change, feels like academic programs are hiring a lot of new radiology attendings and some attendings getting older and retiring so things can change on a dime when it comes to faculty ratiowise- what you get on your ms4 rotation and interview day as a med student and what you end up getting when you become an R1 almost 2 years later is going to be very different for good or bad.

Location matters more than for other fields since radiology is more standardized with all these study materials

Radiology is much more competitive now than past few years, maybe everything is more competitive. Feels like med students doing more aways
/research. Used to be you could pick your location, where job placement is strongest, luxuries like reading room assistants/efficient hospital system, moonlighting to just feel lucky you matched radiology and try to find a better fellowship if unsatisfied these days

Obviously residencies factor research into rank list. But it's probably going to be hard to do any research in residency even if you go to a research heavy t20 because you are busy trying to grasp the bare minimum basics as an r1- literally brand new rotation/modality each month - body msk chest IR nucs Neuro peds mammo, er, r2 is call/er heavy- radiology call is actually the best learning experience, r3- dealing with board review- possibly the hardest boards in all of medicine, r4- not much point anymore.

 

[Aurum]

Agree with much of what the above poster mentioned. As someone who recently took the CORE exam, time off for studying and being on slower/nonessential rotations is critical. Most programs will take you out of the call pool, but if you are assigned to essential, busy services you will be too tired to study properly at the end of the day.

Try to get a feel of how often residents are "pulled" to essential services due to staffing issues. The last thing you want is to be on a coveted, high yield rotation and get pulled to some BS like fluoro. It happens everywhere, but the frequency varies.

Similarly, gauge how flexible the 4th year is. Some programs allow for minimal electives due to coverage requirements, but others may offer near 100% elective time for the PGY5 year.

I would also directly ask about call frequency and call shift length. A 12 hour overnight shift is exponentially worse than an 8 or 10 hour shift. Working a full weekend a month is much worse than working one weekend day per month.

Lastly, try to tactfully ask about vacation. Some programs allow you to take half days of vacation or even offer wellness days, which are a game changer in terms of flexibility.

 

[thatchemguy]

Thank you both for taking the time to write these thoughtful, in-depth answers. I will keep all of this in mind as the interview cycle begins. Just two other comments I wanted to ask - in terms of call schedule, what is considered an ideal amount of night float, or an amount of call in general that is not too overbearing? I realize this may be program-dependent.

Lastly, any advice on choosing prelim year vs TYs and/or if you recommend any studying during intern year for radiology?

 

[guytakingboards]

Besides from the obvious such as a diverse caseload with interesting/complex pathologies, ability to moonlight, etc. what should I be looking for in a good radiology residency program? Currently finalizing my program list and wanted to know what things to help differentiate programs.

What do you wish you knew before applying? What type of call structure/night float is ideal? What amount of faculty:resident ratio? etc.

Thanks!

Fellow-driven vs resident-driven workload is a big thing:

If there's a heavy fellow complement, your education may suffer. I have a colleague who trained at Hopkins who claims to have done zero mammo biopsies during residency. The fellows may gobble up all the advanced imaging and procedures. Flip side, the fellows may shoulder the majority of the workload leading to a more chill experience for the residents.

Resident driven workload can be way stressful too. You can't go home until you've cleared the list. You'll work harder than in a fellow-driven program.

Supervision vs autonomy: will you take true indepedent call? On procedures rotations, how much will you get to do? There tends to be more autonomy in county-based and VA-based rotations than at the bougie quarternary referral center.

I agree with the above poster who said it's important to determine how often residents are pulled to cover rotations. Last thing you want to do is to miss out on learning body/MSK MRI because a 1st year resident is out in chest.

I don't particularly agree with call being significant distinguishing factor. Call sucks... no matter what program you're in. Every resident in every program complains about the amount, length and type of their calls. There's no 'good' amount of call. Some program's call may be better than others but once you're in XYZ program that becomes moot. You will acclimatize to whatever amount of call there is (and you will be unhappy). Cuz all residents complain about call.

If possible, I'd hope you'd find a program that gives you a broad enough exposure to all subspeciaties so you can be well informed before fellowship applications. I personally didn't have body MR or mammo exposure until early 3rd year. While I would have never ended up choosing mammo, I might have done body instead of neuro.

 

[tomballunger]

Call is a huge debate. Where Im at, there's weekend call ranging from q4-q8 for different sections like body, Neuro, chest and there's ER call shifts -12 hr day and 12 hr nights divided into junior plain film/us and senior CT/mr. Through 4 years, people will have about 8 months of ER, but all ER blocks are a month long each, and you work 15 days total in the month, your coresident does the other 15. So 4 months. Some residents and non ER section attendings have said that's too much, other residents say it's better than other programs where the call schedule/night float has it worse and that they learned more in the ER than reading inpatient followups on the weekday shift. So it's always a debate.

Intern years are also a debate. Some say Ty is the best because it's chiller, can customize your schedule to do a mix of medicine and surgery with lots of time off and again, Radiology will have an insanely steep learning curve- no amount of prep will get you ready before R1. For most people, not until you read a lot of imaging studies day in and out and discuss those cases with an attending and go to daily conference will you have a context to start learning from radprimer, core, and crack the core. I'm sure there's someone out there who will disagree and say it's worth studying intern year, radiology people are incredibly smart, and are able to memorize core radiology and crack the core physics during their TY.

Some say do surgery because you learn anatomy, but hours are rough, and most but not all will scut you out on the floor writing notes and doing social work and you never go to the OR and you never learn anything about relevant anatomy/being efficient/how to fully run a service from taking consults to doing procedures and taking care of them afterwards. Medicine prelim is guaranteed social work heavy and babysitting all the subspecialty's pts, but potentially not as bad hours and hopefully not as bad malignancy

 

[Aurum]

Call is a huge debate. Where Im at, there's weekend call ranging from q4-q8 for different sections like body, Neuro, chest and there's ER call shifts -12 hr day and 12 hr nights divided into junior plain film/us and senior CT/mr. Through 4 years, people will have about 8 months of ER, but all ER blocks are a month long each, and you work 15 days total in the month, your coresident does the other 15. So 4 months. Some residents and non ER section attendings have said that's too much, other residents say it's better than other programs where the call schedule/night float has it worse and that they learned more in the ER than reading inpatient followups on the weekday shift. So it's always a debate.

Intern years are also a debate. Some say Ty is the best because it's chiller, can customize your schedule to do a mix of medicine and surgery with lots of time off and again, Radiology will have an insanely steep learning curve- no amount of prep will get you ready before R1. For most people, not until you read a lot of imaging studies day in and out and discuss those cases with an attending and go to daily conference will you have a context to start learning from radprimer, core, and crack the core. I'm sure there's someone out there who will disagree and say it's worth studying intern year, radiology people are incredibly smart, and are able to memorize core radiology and crack the core physics during their TY.

Some say do surgery because you learn anatomy, but hours are rough, and most but not all will scut you out on the floor writing notes and doing social work and you never go to the OR and you never learn anything about relevant anatomy/being efficient/how to fully run a service from taking consults to doing procedures and taking care of them afterwards. Medicine prelim is guaranteed social work heavy and babysitting all the subspecialty's pts, but potentially not as bad hours and hopefully not as bad malignancy

Respectfully, I do not view the intern year decision as much of a debate. I (and every other rads resident I’ve met who doesn’t have a personality disorder) highly recommend doing the chillest intern year you can. I know a ton of residents and nobody who did the terrible surgery intern year is a better radiologist because they suffered. Intern year is a completely useless year of indentured servitude, so at least make it as painless as possible.

 

[Ho0v-man]

Respectfully, I do not view the intern year decision as much of a debate. I (and every other rads resident I’ve met who doesn’t have a personality disorder) highly recommend doing the chillest intern year you can. I know a ton of residents and nobody who did the terrible surgery intern year is a better radiologist because they suffered. Intern year is a completely useless year of indentured servitude, so at least make it as painless as possible.

QFT.

The people who did surgery prelims likely put in 1000+ more hours than me in intern year.

They can tie knots better than me. Thats about it. This is a skill you can pick up if you decide to do IR.

 

[Cognovi]

Look at the general quality of residents and their success.

 

[PhysMatMan]

While I probably would have chosen a cush transition year, I do think I learned some things on surgery that help me be more intuitive and helpful to surgeons when reading studies. Yeah you can learn all this stuff from just studying radiology but actually knowing how the procedure is done and what postoperative devices actually physically look like is a leg up.

 

[pathogeN7]

or if not how easy is it to get in touch with primary teams- very easy to find the primary team and page them to relay critical findings at some programs, others, not so much

Genuine question – what would make it difficult to call the primary team? In every patient’s Epic chart, the contact info for the primary team is readily available, in my experience. Or would it be because Epic is not the EMR used?

 

[Neopolymath]

Genuine question – what would make it difficult to call the primary team? In every patient’s Epic chart, the contact info for the primary team is readily available, in my experience. Or would it be because Epic is not the EMR used?

My sweet summer child.

But seriously and without condescension, this can get messy in so many ways, especially at academic centers with absurd and byzantine structures for absolutely no reason.

During my intern year, there was an on call-list on the home page just in case and basically everyone else had a phone app. Some services used a "role" so if you were working in the ED and needed to admit then you would shoot the role a message for the hospitalist or resident admitting team and the correct person receives the message and then you can message or call from there. Need GI? Then just find the GI on call and call the correct answering service or send them a message if you know they use that reliably or have residents. Have a question during the day for a random service involved in the care of the patient? Shoot them a message to coordinate chatting.

Fast forward to the typical academic medical centers and there is a patient overnight in the ED who got a study ordered. A random resident put the study before going off shift in the ED. You find some problem warranting further imaging when you open the study up at the beginning of your shift. You try to figure out who is taking care of them and after your first message/call goes to nowhere you request the chief in the ED who might know wtf is actually taking care of the patient. Or the patient had a study in the ED and you need to call but they have an H&P by the trauma service in the chart so you message them. They tell you to message the IM group because despite the H&P note they actually didn't admit (which is bs anyways because the context of the message directly pertains to them which is a whole separate issue at academic places.) Then you contact IM and find out that actually heme/onc decided to be primary and got transferred to their service. Now you need to call them to tell them whatever.

It's one of the few ways in radiology you can feel like your time is wasted doing clerical work and you know it can be completely avoided if academic medical centers weren't so stupidly run. It's worth noting this doesn't happen a lot at most programs but it's something you should ask about because it's such a waste of time. Doesn't matter during the day. Really matters at night.

 

[guytakingboards]

Genuine question – what would make it difficult to call the primary team? In every patient’s Epic chart, the contact info for the primary team is readily available, in my experience. Or would it be because Epic is not the EMR used?

As people have said, it can be ridiculously and unnecessarily difficult at times. The primary team may not be the team that ordered the study or the team posed to take action on the study. The primary team listed may just be wrong.

Imagine a high velocity motor vehicle collision patient coming to the hospital. Within the first few hours, ED, trauma surgery, ortho trauma, and NSG may get involved in a poly-trauma case. Conveying information in the 4-12hr range gets hairy some times. Not infrequently I'll read a follow-up 6hr non-con head CT to follow-up a head bleed. By that time, the ED doc may be gone, trauma surg/ortho trauma/NSG are all in the OR and won't return their pages.

One time I asked my radiology assistant to get the doc on the phone because a subdural hemorrhage got worse on the 6hr head ct f/u and despite her best efforts connected me to the off-service ortho trauma intern.... who said "oh, the patient has a worsening head bleed? cool.... we're consulted for the tibia fx but i'll try to pass that on". That was WITH my own assistant. Imagine doing it on your own while your pile of studies grows and you can see where it'd get frustrating.

That being said, in my opinion, this is a nit-picky thing that wouldn't be top 20 on my rank list considerations.

 

[Neopolymath]

Number 1 consideration from a QoL standpoint: vacation days/sick days that can be taken on short notice if appropriate and as half days if desired.

 

[Cognovi]

Look at the degree to which you can customize your education to suit your career goals. This includes 1) areas of professional development aside from clinical radiology (eg, research, education, innovation/entrepreneurship, quality, leadership, informatics), and 2) subspecialization in clinical radiology.

What do I mean: Does the program support residents (in time and money) in attending national conferences (eg, ACR) and courses (eg, ITAR, NIIC, PGME)? Do they have mentors, academic or elective time, or an established curriculum in the area? How much of your R4 year is spent in required general rotations and call? To what degree are R4s treated like fellows in a subspecialty area?