Eric Postal, MD, is a diagnostic radiologist with the University of Pittsburgh Medical Center. 

Eric Postal, MD

Once you notice certain things, they suddenly seem to be everywhere. Theses things are often annoying. One thing that I noticed a few years back was the tendency of tabloids (and subsequently my Internet news feeds) to have headlines hyping numerical lists. Chances are that you have seea few of these headlines. 12 ways to lose weight before the holidays! 7 habits of highly successful people! 13 actors you've completely forgotten about but are still out there!

Partially, it got under my skin because I wanted to know how the industry had glommed onto this gimmick, and why they knew it would be successful. Did they just stumble across it, or had psychological types somewhere figured out that it was a semi-magical formula for attracting readers?

I still don't know, but clearly it works because it is still going strong. Near as I can tell, there aren't certain numbers that work better than others. This is kind of funny since many of these lists include pure fluff, or things that anybody would know without reading the pieces. Why include three wasteful items in your list of nine when a headline boasting six would have done just as well?

Whatever the case, I figured I might as well make use of the trick for one of my blogs. My radiological career hasn't exactly been traditional, so perhaps my perspective from off the beaten path will be of interest to those who remained on it.

 I could have sworn I wrote a blog about this at some point, but a search of my records indicates otherwise. Your motivations and metrics for professional success, career satisfaction, etc. should be the ones that guide you. Whether you are an academician or private practitioner, onsite or telerad, diagnostician or interventionalist., feel no shame or pressure if someone who chose a different path takes a poke at yours. (Don't go poking at colleague career choices. It's not a good look.)

 Unless you happen to hit the lottery or find other reason to retire early, you're in this career for the long haul. Multiply whatever conditions you're thinking of enduring (or enjoying) by a pragmatic factor of forever. Perfect situations are vanishingly rare, and holding out for one isn't a great strategy. try to think about which seemingly minor "I can put up with this for now" imperfections today will evolve into "I can't take this anymore" in a few months or even years.

 You probably can't remember the first few times you read any particular type of study in residency, but chances are you recognize how much more efficiently, quickly, and accurately you do it now. Part of what happened was that you developed good habits. These may include a search pattern when looking at the actual images, hanging protocols and dication macros that work best for you, etc. When a good habit is ingrained, it takes less energy and effort but habits can be unlearned too. Be on guard against slacking off. For instance, some may consider skipping review of sagittal and coronal recons if the axials looked totally normal. However, not doing it once or twice can lead to doing it rarely if at all. Also, it doesn't matter how old and wise you get. New good habits can always be learned.

4) That goes for non-radiological stuff too.

 You could have the best set of professional skills out there, but that radiological brick house isn't going to remain all that impressive if it's missing a decent foundation. Short yourself on sleep, eat bad (or too much) food, or fail to get regular exercise, and it will impact the rest of your performance. Such things are perfect examples of habits trumping conscious effort. If getting to bed on time is part of your routine, you'll do it far more automatically and reliably than if it's a nightly toss-up whether you notice the clock while you're rewatching your favorite movie for the gazillionth time.

 One tends to compete with others of similar capability. It doesn't matter if you're a rad, an engineer, or a professional athlete. Aside from the extreme outliers (at both the superstar and scrub ends of the spectrum), there's usually very little individual difference in performance. If everybody in your practice reads with 99 percent accuracy, for instance, how likely is it you'll be celebrated for doing 99.1 percent? So don't let that be the only feather in your cap. Choose easier ways. Show up on time, answer emails or return phone-calls promptly, and generally make dealing with you a pleasure. You might be amazed how many colleagues get left in your dust.

 An awful lot of people can't. They cling to what is known, whether from a considered appraisal of the devil they know, or simpler things like ignorance of what else is out there and laziness against pursuing it. The more one has to lose, it seems, the stronger the inclination to "stand pat." A lot of opportunities can be missed this way and, not uncommonly, the status quo gradually deteriorates even as folks cling to it. Don't needlessly imprison yourself. Throw out the excuses and be willing to consider the potential of new opportunities.

 It can be tricky to find time for anything extra given the hours some rads can pull, especially when you count in ancillary obligations like CME. The "lifestyle" things I mentioned above (adequate sleep, exercise, even a social life) also take chunks out of the day. But try to find opportunities to "feed your head” as the song says. In addition to the value of simply broadening your mind, you never know when some of the stuff you pick up might synergize with your professional life. Building a "talent stack," as podcaster/author/artist Scott Adams writes, can come back to benefit you in all sorts of ways.

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Building a career for the long haul requires a foundation of good life and work habits as well as an openness to innovation and change.

Seven Personal Truths from Charting My Own Radiological Course

If you have been reading this blog long enough, you know that I have more than dabbled with video games over the years. They were a lot simpler when I got started. Those of sufficient age can think back on "Pong" as compared with, say, 

Part of the evolving sophistication of video games was to offer more challenges than simply beating the other guy or working your way through a bunch of stages to face the Big Boss. Optional side quests became a thing as did finding an assortment of hidden loot. Games started tracking and scoring your progress in these ancillary veins. You might actually win but still be told that you had only done 67 percent of the stuff you could have. (At that point, you would stubbornly go back for the other 33 percent or just consult YouTube to see if anything interesting happens for reaching 100.)

Along the way, games also started offering "achievements" for doing various things, little digital trophies attesting to your greatness. I recall stumbling across one that proclaimed the player a "completionist" for making efforts to delve into every nook and cranny. Evidently, it was already an established term among gamers.

By then, I had long since stopped being a completionist in these things. The video games had gotten sufficiently complex to the point where it was too annoying and time-consuming to track down and do absolutely everything. Still, my attitude adjustment did not come too easily. I was still very much a completionist in other walks of life.

I was one of those kids who settled down and focused on something, like my homework or cleaning my room until it was done. Do some now and do the rest later on? That wasn't my style. An unfinished task would eat at me. That became an issue later. Ten-page term papers don't happen all at once. I suppose that was meant to be part of the lesson.

I think “completionism” (hey, as long as we're using made-up words like "completionist," let's go whole hog) has got to be prevalent among physicians. One doesn't typically breeze into/through medschool without a penchant for learning vast amounts of stuff and regurgitating it on command. A completionist attitude ("I've got to master every last bit of this material") is adaptive if not downright necessary.

It is also the sort of attitude expected of physicians along with other professionals. Don't you want your doc to consider everything and resolve all of your issues? Wouldn't you want your accountant, standing between you and an IRS audit, to be a completionist who is able to defend every penny? Would you be satisfied with a lawyer who got 75 percent of the job done and then seemed ready to mail in the rest?

Radiology may be the medical specialty in which completionism is most expected. All but the greenest rads have heard, many times over, about how they are responsible for everything on the images. One has to be a completionist, or at least have a completionist's diligence and search-pattern, to reliably examine and interpret everything.

Completionism helped select me for this field and enables me to do a decent job now that I am in it. It is no small surprise that it rears its sometimes ugly head in other ways while I am at my post.

Yes, it can get ugly. Health care isn't always the best field for a completionist. The work is never really done. Even if you read all of the cases on your list, more will eventually turn up. That's a good thing if you want to remain needed/employed but if you only feel truly satisfied when you have gotten everything done, you are liable to spend a lot of your time unsatisfied.

You might even feel a little resentful when new work comes your way. It would be akin to a kid who has dutifully cleaned his room, but somebody else periodically comes along and dumps more stuff on the floor.

I have worked in some places where the worklist (or bin of film folders for those who remember) was, in fact, possible to empty. It was very gratifying to do so but living in such circumstances can develop maladaptive expectations if you go on to other places that operate with a perpetual backlog. Folks can notice you getting your stuff done when others do not and respond by developing higher expectations for you sans matching reward.

When the day came that I moved to per-click telerad work, my completionist world got turned on its head. The absolute last thing I should pragmatically want was to deplete my reading list. Having nothing to do would mean zero income while I sat there waiting for new cases to show up.

Still, it did happen sometimes and the completionist in me wound up at war with my desire for productivity. I could sit there simultaneously feeling pleased with my prowess but also fretful and annoyed about how my next paycheck would be smaller than it should be.

Most rads don't have much control over this sort of thing. We get access to however many cases we receive. If that turns out to be a volume we can completely consume, whatever completionist tendencies we have can be gratified. However, just a single case beyond our capacity might as well be a dozen, just like drowning can occur whether one is submerged an inch or a foot below the water's surface. For a completionist, excess cases might indeed feel like drowning.

In an ideal world, completionists would be able to find jobs where getting "all the work done" was achievable, and non-completionists would settle into places where getting caught up would be a "never event." I suspect most would prioritize other things. For instance, I left a completionist-friendly job when it welched on promises of partnership, and another gig offered more money for fewer hours. Furthermore, even if I happened to land a completionist gig that suited me today, the only constant is change, and it might be a non-completionist place in just a few months.

The best compromise I have found is being a "situational completionist." Most of us can't turn our motivations on and off like a light switch but learning to modulate can be a big help. I find that it is best to keep my completionism dialed up as long as there is work to be done. It surely helps my productivity, but I remain capable of dialing it back. For instance, any time I see the worklist is bursting at the seams, I know there is absolutely no way I am getting through it all. Being a completionist doesn't need to include tilting at windmills.

The ebbs and flows of worklists in radiology require equal parts productivity and preservation.

Why Being a Situational 'Completionist' is Perfect for Modern Radiology

I spent an extended Halloween weekend in Salem, Ma. this year. It had been on our "bucket list" for a while and one pretty much has to book a year in advance to get decent accommodations.

Lest your history classes were deficient or simply too far in the past for proper recollection, Salem's claim to infamy was a witch-hunting craze that seized the place in the early 1690s. One can take the subject as lightly or seriously as one wants when visiting Salem, from buying goofy merchandise to visiting historical sites.

We did both and were reminded of various reasons why the witch-hunting trials went as far as they did. One factor was the admissibility of "spectral evidence" in court. A witness could offer testimony that the accused's spirit ("spectre") had appeared to them as a result of supernatural powers granted by the devil.

It doesn't take much imagination to see how this stacked the deck in favor of the prosecution. When the jury is ready to believe accusatory "evidence" that is 100 percent subjective (if not entirely made up), what can one do in the name of cross-examination?

Most treatments of the subject matter acknowledge that, yes, folks are much more sophisticated nowadays. However, we shouldn't pat ourselves on the back too proudly over how we have evolved. There are other much more recent events thatv echo the witch-hunting trials. The Salem Witch Museum points out the "red scare" and McCarthyism just a few decades ago.

Everyone is capable of rushing to unfounded judgments. We may not take it as far as hanging people or otherwise ruining their lives. However, I have noticed how eagerly folks will allow themselves to consider flimsy or non-existent evidence as justification to form opinions and take actions.

One might hope, if not expect, that a good education would help counteract this. For instance, most folks who've gone through medschool have learned about things like confirmation, hindsight, and anchoring biases (amongst others). Being aware of common ways that reasoning goes awry should help us avoid drawing conclusions based on faulty evidence, right?

Unfortunately, I have seen that such education can also be a liability, and scientific pursuits including radiology are not at all immune. It is dangerously easy to assume one's learning and experience are nigh-impenetrable defenses. If I decided that X were true -- passing the muster of my education and experience -- I might consider X as proven as anything needs to be.

Some efforts are made to teach residents to remain humble in this regard. Consider, for example, the potential impact of "satisfaction of search" (aka "happy eyes"). Identifying an abnormality on an imaging study, especially one that answers the clinical question, has a way of dialing down our efforts to make other important diagnostic finds. In a way, we can be tempted to accept the "spectral evidence" that we have found the salient abnormality, render our judgment, and prematurely move on.

Another spectral evidence mimic is a leading clinical history that can bias us toward certain diagnoses (or lack thereof). For instance, suppose you receive a full-body CT for "mechanical fall," "found down," or the like in a nursing home patient who has had a dozen similar negative scans in recent years. You might be predisposed that CT image will also be a completely negative waste of time (or you might consider it quick and easy RVUs for zero injuries).

Alternatively, suppose you get the same scan, but the history tells you the patient fell out of a second-story window, has an obvious hip deformity, and is unable to bear weight. Convinced you will see a fracture or dislocation before you even see the images, you might have trouble believing your eyes when there is absolutely nothing there, not even a hematoma. In this situation, one might be tempted to hedge rather than rendering a normal report.

(If any referrers are reading this, please, please do not think this makes it okay to withhold pertinent history on that grounds that it "might bias" the radiologist. For anybody who thinks that kind of behavior is okay, please do everyone a favor, and go find another line of work.)

If we're vulnerable to spectral evidence when doing the image analysis for which we have been rigorously trained, is there any chance we're immune when dealing with the ancillary stuff surrounding it?

Suppose, for instance, you receive the aforementioned scan with no clinical history whatsoever. You might be ready to jump to all kinds of summary judgment about the referrer (thinking he or she is lazy, doesn't care, or is disrespectful of the radiology consultation ordered), the clerical staff who handled the referral, the CT tech who received the case and didn't get you an actual reason for exam, the order-entry system, or the hospital, etc.

Any of these judgments might turn out to be right or you might just assume them to be since you move on with your day and never get any evidence countering your appraisal of the situation. This may especially be the case if you have made similar unchallenged judgments before.

One susceptibility to faulty decisions is if they suit an established personal narrative. If you have already accepted the notion that we get lousy clinical histories because of laziness, incompetence, crummy infrastructure, etc., any new referral can get thrown into the same mental bucket. It is the same deal if you have a gut instinct that all "altered mental status" brain scans are going to be negative.

Such narratives (and faulty conclusions based on spectral evidence) may also factor into perceptions of higher order things, whether they are policies and politics in your rad group, or the overarching hospital system affiliated with the rad group.

Do our assumptions and “satisfaction of search” prevent us from digging deeper on imaging reads?

Spectral Evidence and Other Poor Foundations For Decision-Making in Radiology

With elections being just around the corner, I recall a particular episode of the Britcom 

 that took a swipe at politics. Asked how he plans to win an election, the titular character replies, "Firstly, we shall fight this campaign on issues, not personalities. Secondly, we shall be the only fresh thing on the menu. And thirdly, of course, we'll cheat."

Cheating is a funny concept. The dictionary definition is pretty clear-cut as is the mindset of one who believes he or she, or someone the person supports, has been cheated out of something. Under such circumstances, cheating is considered a pretty lowdown, no-good way to behave. Of course, if you ask the accused cheater, he or she will give you a very different accounting.

However, one of the weird facets of cheating is that pretty much everyone would agree that, under the right circumstances, it can be the proper thing to do. If that statement sticks in your craw, you probably haven't let your imagination sufficiently loose.

For instance, suppose a madman has a gun to a hostage's head, and tells you to flip a coin. If you get heads, he will shoot the victim dead. But if you get tails, he will drop the gun and allow himself to be taken into custody. Now you get to flip the coin and tell him the result. (For the purpose of this scenario, consider it a given that, as result of his madness, he will unquestioningly abide by your answer).

I'm just going to say it. If you get heads and play fair, causing the hostage to die, there is something very wrong with you. The right thing to do is cheat and say that it came up tails.

One could apply this notion to elections as well. Suppose you knew with certainty that the modern-day equivalent of Hitler was about to be voted into power and was on the precipice of doing nightmarishly bad things. Perhaps you and some of your allies some allies have the ability to cheat and tip the outcome of the vote so Hitler loses. Many, I daresay most, people would consider it a moral obligation to do so.

In my life as a radiologist, I might be considered an unabashed cheater. I use every trick I can think of to do the best diagnostic job I possibly can.

A lot of cheaters, myself included, don't admit, or even necessarily consider that what they do is cheating. When I cheat, the rules I break are the ones that were taught in residency about how to practice what I'll call "pure" radiology. They are good rules for learning and to pass on to trainees of your own if you stay in an academic setting. They center on the idea of interpreting images in the absence of any other information.

Again, this is a good thing for someone learning to practice radiology: You want to be able to extract as much diagnostic info as possible from the pictures, without leaning on crutches like clinical history, results of previous imaging studies, or patient demographics. Any of these may bias the interpreter and cause him or her to favor one diagnostic possibility or exclude others. Also, as you might have noticed from previous blogs of mine, such ancillary information, when present, can be dangerously misleading.

In case conferences during my training, someone projecting a film (yes, we were still using those for the most part) would usually make a point of covering the patient gender and age. If the resident were to ask about this info, the answer would be dismissive. You don't need to know that, and you had better not ask such questions when you go to Louisville because it suggests you are stuck and unable to say anything useful about the case as is.

(If you're asking what Louisville has to do with any of this, clearly you're not a radiologist of a certain age.)

A rad resident playing by the rules might say things like "If this was a young female patient, I'd be thinking about diagnosis X. But if this is an elderly male, I might be thinking Y." In addition to getting his or her evidence purely from the images, the trainee would also get that much more educational value from the experience, talking about two or more hypothetical patients from a single study.

It has been a while since I was in training, and I have nothing to do with teaching future radiologists. Playing by those rules might have a certain purity to them, but everything I do is in the name of giving the best diagnostic results I can.

I look at the patient demographics up front. I sift through whatever documentation I can get about the patient, including notes jotted down by the tech and prior imaging-reports. They will almost always tell me way more than whatever the referrer (or clerk) wrote on the "reason for exam."

Outside of a super STAT situation like major trauma or a possible stroke, I don't waste anybody's time first looking through the current images in the name of not "biasing" myself with any other valuable info I can get. To my way of thinking, that's about as helpful as reading cases with one eye open. “Hey, watch me show how good I am by reading this case with extra self-imposed obstacles!"

This isn't the Radiology Olympics (bonus points for anybody reading this blog long enough to remember that invention of mine). We're not competing for "love of the game" and eschewing unfair advantages against other rad competitors. I guarantee that patients and referrers would far more appreciate their rads using every trick they can think of to do the best job. Speed is another consideration. The 10th patient on your worklist probably wouldn't appreciate the idea that his or her interpretation was being held up because the previous nine cases were being treated as some sort of game.

Is due consideration of patient history, demographics, and previous imaging essential or a cheater’s crutch when assessing new imaging?

Musings About Elections, Cheating and 'Pure' Radiology

"We're limited." I heard that utterance more than a few times during my fellowship, nearly 2 decades ago. It was often spoken by one of the attendings, when she'd open an imaging study and see it marred by motion artifact, bad contrast-phase, wrong positioning, etc.

She'd say it in a particular tone of voice, a mix of regret and disappointment. Both understandable: Here we were, all set to showcase our diagnostic capabilities, and we'd received crummy tools. We stood to accomplish less for a patient than we otherwise might have.

Still, something about it didn't sit well with me. I can't say exactly when I put my finger on it, but when I did, my sentiment crystallized: “

I'm far from perfect, radiologically speaking or otherwise. Even having come to understand that I am often my own harshest critic, I know that I have plenty of limitations. Perhaps I could/should have overcome more of them by this point in my life, but I think I can forgive myself for not outrunning Usain Bolt or out-physics-ing Stephen Hawking.

Saddled with all the limitations I've got by virtue of circumstances and being an imperfect mortal, I don't think I need to take ownership of any extra. When it comes to doing the best diagnostic radiology work I possibly can, for instance, I categorically refuse to take an iota of blame when I'm given a lousy case to read.

Sure, my name is going on the report, and whoever reads it­—especially hungry ambulance-chasers—might well try to tie the inadequacies of the images to me, personally. Let that be their burden; I won't do anything to make it easier for them. That includes not beating myself up over the matter.

Maybe that sounds callous. Or an abdication of responsibility, if you're of the belief that radiologists have the ability to take corrective action in the name of quality-control. I like to imagine that other rads out there do indeed work in environments where they can identify problems and either personally fix them or talk to someone who can (and, most importantly, will). That goes for anything from subpar hardware/software to personnel–whatever results in imaging being performed or analyzed in a less-than fashion.

I, personally, haven't worked anywhere that functions that way. I've worked in places that gave lip-service to the idea. In my residency, for instance, one MSK attending would often tell the house staff that they should "teach the techs how to take better films."

Maybe the techs would've taken direction from him, but I can guarantee you it wouldn't go down that way if anyone less brilliant than he tried to pull that off. A resident would at the very least get yessed, maybe laughed out of the room. Probably resented.

In my first few jobs post-fellowship, I received all sorts of verbal support from the folks in charge: If the imaging wasn't great—especially in my areas of subspecialty expertise—I should speak up. They'd support me if I needed it.

As a not-so-big surprise, they didn't. When push came to shove, it was more feasible to retain techs who didn't know (or care) to do better than it was to search for new, better ones (who might need to be paid more.) Same went for less-than software, hardware, etc.; Saying "we have the best" doesn't necessarily translate to buying and maintaining the actual best.

Meanwhile, I'd been living in the world of limited radiology for over a decade at that point, and it was clear that people with a lot more clout than I were no more effective at forcing quality. They were working in the same places I was, sometimes bearing impressive titles that presumably gave them the authority to make things happen, but the limited studies never seemed to go away. They certainly complained enough about the issue, so it wasn't a matter of not caring.

If I retained any illusions that I could go on a quality-crusade and fix things, they vanished as I started doing telerad. Whatever clout I had working onsite in small radiology groups, it didn't translate as I became one of hundreds of remote telerads who each covered dozens of facilities. "Hey, can we have Hospital #493 start uploading prior scans without our having to ask for each and every one?" "Sure thing, Chief. If we beg them for another few years, they'll eventually start taking us seriously."

Maybe it was also a sign of the changing times, or maybe it was that facilities offloading their work to telemedicine tended to be on a lower rung of the quality-ladder, but studies seemed to get more limited as time went by. It's become a rare thing that I get a chest CT that isn't full of respiratory-motion artifact, even when it's in the outpatient setting for following nodules. Are the techs even telling the patients they should hold their breath, anymore?

When I'm feeling particularly cynical, I almost appreciate the limited stuff I receive, especially the truly god-awful stuff. At some point, a study gets so ruined that, as one of my old attendings used to say, "It's so hard that it's easy." A sufficiently mangled scan, with zero contrast and a dozen different types of artifact, becomes a blissfully quick read. Anything you manage to diagnose (or rule out) on it makes you a hero. Plus, the way our RVU-system works, reporting out a nondiagnostic scan pays you just as much as a good one would have.

Am I happy about the state of affairs? Of course not. Although I've chosen the serenity of accepting what I can't change about my profession, I can still wish it were otherwise, but part of that serenity includes not lumping myself in with the limitations that surround me or feeling guilty about them.

They're not my fault, and if I were given the ability to fix them, I would. I can live with that.

Rads will always have to deal with forces outside of their control, but it’s how we address those forces that makes us the type of radiologist we can be proud of. 

Quality Control in Radiology: Knowing Your (Un)Limit

A few days ago, a headline caught my attention during routine browsing of the news. It was something to the tune of “Gaming supplements might be harmful to children.”

I didn’t bother clicking on it because it seemed stupidly obvious. The line between nutritional supplements and pharmaceuticals is vanishingly thin, poorly defined, and mutable. If you can keep your product in the former category, you are pretty much doing business in the Wild West. Of course, supplements might be dangerous, especially to kids.

Hours later, I had a delayed double take. Wait a second. What the heck are “gaming supplements?” I get the point of supplements for athletes, who can have substantially greater needs than the average person. I also understand how other folks might see value in self medicating or preventing conditions real and imagined, but supplements to help you play video games? That couldn’t be what the piece was about.

A quick online search confirmed it. Yes, that is exactly what this stuff is for. There is apparently enough widespread use to prompt news items, even medical concerns. I would have guessed these supplements are various concoctions of sugar and caffeine. This could be akin to someone guzzling energy drinks to stay awake, alert, and twitchy as they play for hours on end.

It seems those raking in the bucks knew they had to go above and beyond what was already available though. Glancing through some of the offerings, I also saw ingredients like ginkgo biloba, omega-3 fatty acids, L-theanine, ginseng, rhodiola, taurine, all things you could easily get with a normal diet, or as stand-alone products already available.

A key of the supplement-game is to hype how your product has just the right amounts of each of the valuable ingredients, leaves out pointless stuff, and tastes good. Customers are buying the illusion that the sugar-water they are drinking somehow has good stuff they wouldn’t otherwise get. Call it a happy coincidence if it makes them a little euphoric in the process or recognize it as a business strategy. Either way, it’s positive reinforcement to keep buying and ingesting more.

Still, I wondered who contemplated gamers and thought, “now there isan untapped revenue stream.” True, there are some folks who manage to game for a living, or like it enough to avidly play long after they’ve become adults and have disposable income to bankroll expensive habits. Surely, the majority are kids begging Mom and Dad to buy them their toys. How much of a goldmine could that be?

Far from the first time, I found myself dwelling on the numerous similarities between diagnostic radiology and video gaming. I am far from the only one, and surely not the first. For instance, one of the hardware-peripherals that vRad used as part of their teleradiology workstation was the Grip, a device to be used with your non-mouse hand. It had buttons for each of your digits, so you wouldn’t waste time with keyboard shortcuts. The Grip had originally been developed as an ancillary video gaming input.

It would take someone far more into research and number crunching than I to intelligently comment which industry poses a juicier financial target — video games or radiology —but at the very least, it's safe to say they are both eminently worthwhile. That being the case, I have to wonder why gaming supplements are a hot item, while nobody is trying to make a buck by marketing similar stuff for rads.

One might argue that there are far fewer radiologists out there than video game players. However, an average rad puts in a lot more hours at work than the typical gamer. That has got to balance the scales somewhat. One might also imagine that rads are savvier about health-related matters and less readily enticed to guzzle snake oil supplements. But think for a moment about the rads you have seen. How many of them really look like they know or care about how to take care of themselves?

It seems that pretty much any competitive environment lends itself to peddling supplements. Anybody looking to perform better or have some sort of edge over the competition is a prospective buyer. Powerful as the placebo effect is, even if your supplement doesn't actually accomplish anything, a decent number of users will believe it does, and thus become repeat customers. If you get a team leader or employer on your side, that is even better. They can stockpile their break rooms for any number of underlings, and maybe even pave the way for sponsorships.

I can just imagine a rad group with some name recognition and financial backing, throwing their hat into the ring. Perhaps there would be Duke University Rad Juice, or Mallinckrodt Institute's RVU Tonic. If the best rads claim to be doing their best work when swilling their version of a leading energy drink or supplement, how could "me too" purchases fail to follow?

Lest you wonder why any outfit with a decent reputation might risk cheapening it this way, just think of how our radiological bread gets buttered. Most of us have one source of funding: reimbursements for imaging studies. See how many folks in our field are optimistic about where those reimbursements are trending. An alternate stream of revenue would be awfully reassuring to a lot of people.

In a world where “gaming supplements” are available for those obsessed with video games, could radiologists be the next target for snake oil “energy” concoctions of sugar and caffeine? 

Could Radiology Supplements be the Next Revenue Stream Opportunity?

After residency and fellowship, I realized I would have more than four weeks off per year. Not knowing what to do with it all, I stopped evenly spacing out vacations around the calendar. Some breaks from work were more clustered than others.

However, I discovered that it didn’t seem to matter how long it had been since my last vacation. Whenever one was coming up, I would just then feel like it was in the nick of time. All my frustrations and dissatisfactions with work would surge to a peak. It didn’t matter if my last time off had been two weeks or five months earlier.

I am experiencing a similar phenomenon as my workplace is about to go live with a totally new rig for its telerad division. This will cover hardware, PACS, RIS and voice recognition as well the operating system. I may be setting myself up for disappointment by thinking so, but it seems like everything is about to improve in a big way.

Accordingly, as I work through my remaining handful of shifts with the old setup, it feels like I am just now on my last nerve with everything it gets wrong. If the new apparatus were to arrive in January instead of this month, I suspect I wouldn’t have budged from my disgruntlement baseline at this point.

Working from a home office, I have the fringe benefit of being able to mouth off at my telerad rig when it’s misbehaving. It is the sort of behavior that might make me look like a complete lunatic to other rads, support staff, or referring docs who could be within earshot if I worked onsite.

As I was expressing my frustration to my dumb machine when it tried to prematurely sign off a report for the nth time this past week, the thought suddenly occurred to me: Wouldn’t it be great if the machine weren’t so dumb?

By that, I don’t mean that it did a better job at everything it is supposed to do. We all wish for that, pretty much every time we use imperfect technology for anything. We express the wish to our colleagues, to our leadership (who, we imagine, have the ability to get us better tools if we just ask them the right way) and really anybody who will listen. Heck, we would shower our wishes upon the manufacturers who give us these things in the first place but I did say “anybody who will listen.” That doesn’t seem to describe them.

Perhaps because of all the chatter about artificial intelligence (AI), I suddenly realized: This could finally be a role for AI that I would welcome if anybody developed it. Forget about AI that tries to help analyze images, or organize reports. I have yet to see that do anything helpful for me. No, let AI be the listening ear when I have gripes/wishes about the imperfect tools I have for doing my job.

Part of what makes us feel like we’re being listened to is an appropriate response. As things stand, if I tell my workstation that it’s pathetically bad for making the same voice recognition mistakes today that it did half a year ago, despite my faithfully training it along the way, the dumb machine just sits there. I might as well talk to the wall or send an email to the voice recognition company’s CEO for all the impact that would have.

Suppose, instead, there was an AI on my system that understood when I was venting at it. Let there be something resembling a consciousness that seems to feel bad when I tell it that its software is doing a lousy job for me. Better yet, let it respond, telling me that my feedback will help it improve things. Even if that won’t happen, let the responses give me the illusion that I’m being heard. Also, give me the ability to tell it “Good job!” when it earns positive feedback.

This might be a fun toy, and a way for rads to relieve some stress. However, just a little bit of extra sophistication could provide a lot more utility.

Long-term readers of this blog might recall an idea I have proposed in the past: a button somewhere on the desktop that a rad could click on and dictate a quick message whenever he or she was experiencing a problem. This could be related to a software bug or some aspect of the rig that he or she wishes had more functionality. Hit the button, dictate your piece, and the message gets sent to the inbox of someone who might be able to do something with the feedback. The rad gets the bee out of the bonnet right away, and no valuable ideas are lost between that moment and the next departmental meeting.

My current idea goes one step further. The AI is the recipient of all such feedback from rads who are using the system. It aggregates the data, and organizes it so stuff about voice recognition is separated from stuff about the PACS. Further, at the moment any feedback is submitted, the AI has access to system diagnostics so it knows whether there are extenuating circumstances that might be at fault. The issue may be caused by a struggling server, for instance, or a workstation that is currently overtaxed because the rad has a dozen other processes running in the background.

In essence, the AI would be a radiology version of Alexa, Siri, or Bixby. It would be our own workstation concierge with the ability to respond intelligently and sometimes provide solutions.

In addition to being able to give the user on-the-spot explanations or fixes, the AI could also identify trends to bring to the attention of the software administrators for the radgroup, or even the manufacturer. Let the biggest, most frequent offenses be highlighted as “action items” for the next software upgrade.

If you really want a powerful AI, give it the ability to make tweaks to the software when enough individual complaints identify the same issues.

In effect, an awful lot of the problems that routinely have rads wondering whether it’s worth their time to contact support staff could be handled by a decent AI. Unlike a finite support staff, the AI could be Johnny-on-the-spot for many users at once, whether fit is for momentary venting or feedback with potential for substantial systemic improvement.

While artificial intelligence (AI) models have been acknowledged for aiding imaging analysis or facilitating workflow enhancements, this author envisions AI as a potential workstation conceierge capable of turning common venting and gripes into actionable items for significant improvements.

What Would the Perfect AI Do for This Radiologist?

I recently got an unexpected series of emails in regard to a comment I made on a Twitter thread. The thread had begun with a lament about radiology departments directing their efforts and budget to newfangled things like artificial intelligence (AI) rather than traditional elements of their infrastructure (PACS, radiology information system (RIS), dictation software).

I had commented that, unfortunately, it’s not as flashy to boast “We have the same type of software products as everybody else, but our products are quality” as it is to brag “We have something cutting-edge that nobody else does,” even if the cutting-edge stuff doesn’t get the job done. I added that the sad truth of the matter is people who have authority to allocate resources are often more motivated by flash than function.

For a typical radiologist’s perspective and many non-rads, this seems a no-brainer. Why would valuable resources be thrown after gimmicky new fripperies that might not even work instead of applying them to tools that are routinely used to make ends meet?

For instance, suppose I have a clunker of a car that routinely fails to start, stalls out or otherwise dies midway to my destination, not to mention getting lousy mileage whenever it does manage to work. Shouldn’t I make fixing it a priority or replacing the whole thing with something more reliable and efficient? Wouldn’t this be a better approach than tricking it out with a new paint job, spoilers, and ground effects?

Now suppose I depend on that car to make my living. Perhaps I need it to commute to my job or perhaps it is central to my job (such as driving for Uber). Making the vehicle more reliable enables me to keep paying my bills. Fixing/replacing it will not only “pay for itself,” it may improve my bottom line as I subsequently need fewer emergency repairs, get more gigs done and/or bonuses for actually showing up on time, etc.

None of this will happen if I instead choose to detail my vehicle. Guys on the street corner might be impressed as I drive by (assuming I don’t break down in front of them), but they’re not the ones paying my bills or talking to my boss, clients, etc. about what a cool driver I must be.

Even if someone related to my livelihood sees my tricked-out vehicle, he or she might not be impressed with my choices. Instead, if that person has heard I often cite car trouble as a reason I fail to show up, he or she might decide I’m not a smart or reliable person. Alternately, that person may resent having to cover for me at times and here I am blatantly doing nothing to improve the situation.

Seeing someone make such seemingly illogical choices, I always try to remember there are any number of things I might not know or understand about their situation. There could be a reasonable explanation that would have me nod and think, “Okay, now that makes sense.”

Without that intel, though, I’m liable to think that the individual either doesn’t understand things well enough to make better decisions or doesn’t care to make better decisions. My conclusion will surely be colored by the details of the situation. I am unlikely to assume a teenager who tricks out his clunker car has a wise rationale. However, if a CEO does something that makes no sense to me, I have to imagine he or she may have valid reasons.

Still, someone in command of a radiology group who decides to throw resources at AI instead of PACS, RIS, voice recognition, etc. is far from immune to scrutiny. This is especially the case if the latter stuff—the tools that literally make it possible for the rads to pay the bills and keep the group afloat—is constantly breaking down, working at a fraction of the speed/efficiency it should be, contributing to lower quality work, or burning out the rads who have to live with it.

Unless that AI is somehow going to counterbalance the bargain basement nature of the other infrastructure (or it magically comes with a reliable, separate stream of revenue to pay for itself), it sure looks like whoever decided to get that AI either doesn’t understand or doesn’t care how badly the existing infrastructure is hurting the group.

That can easily happen when the decision-maker is someone who doesn’t work “in the trenches” with the other radiologists. Someone who doesn’t regularly experience the inefficiencies and other flaws in the infrastructure might not be all that motivated to fix them. She or he might not even get that there is anything to fix.

At the very least, a leader who doesn’t put in time on the worklists but listens to and respects working rads would have a chance of understanding what needs fixing and/or replacing. I emphasize that second part because it’s all too common to be dismissive: “Oh, you know radiologists, they always complain about X.”

Such an understanding paves the way to appreciating that improving the rads’ tools can boost overall productivity, quality of work, and team morale by a staggering amount. This more than pays for itself and maybe helps a rad group afford extras like AI in future years when the technology will unquestionably be better than it currently is and likely cheaper as well.

Take away that firsthand (or close secondhand) comprehension of the state of affairs, and it’s not hard to imagine why leadership might leave a crummy infrastructure in place. Why throw more resources at new PACS, RIS, etc. when, as far as you can tell, the systems you already have seem to get the job done? Besides, everybody has that stuff. Let’s go get ourselves some sort of AI instead and be the first rad group in town with one!

Addressing upgrades of traditional infrastructure used in everyday radiology practice may be a more practical use of resources than investment in artificial intelligence (AI) technology that is still evolving.

Flash Versus Function: Does the AI Focus in Radiology Compromise Our Infrastructure Needs?

Last week, after poking a bit of fun at the idea, I started to share my vision of what a teleradiology fellowship might look like. It included didactic sessions regarding the administrative and logistical stuff that underpins any viable telerad practice. However, I didn’t get into what the fellows would actually be doing with most of their time.

The first type of rotation, as I mentioned last week, would cover 

new material that most radiology residencies completely ignore

. This would include the IT infrastructure that makes teleradiology possible. This knowledge is also vital to modern onsite radwork unless you happen to still be using films … but there is a key difference.

Suppose you’re working in your hospital or imaging center, and suddenly your workstation isn’t doing what you need it to do. Perhaps the software is crashing, your connection to the network is lost, clicking the mouse doesn’t do anything, etc. Maybe you’ve got enough savvy to try this or that, and sometimes your flailing might even work.

However, unless you have been extremely lucky in this field, that is far from the norm. Usually, you wind up limping along at half-speed if you’re not completely dead in the water. There is not much to do but shrug and take a break until tech support gets around to your rescue. Could that be awhile? Sure, but you can’t do much else. Besides, you’re salaried.

Unfortunately, this is not the case in many walks of telerad life. Even if your compensation is not entirely pay-per-click, chances are productivity is still a big piece of your action. Every moment taken away from your ability to read cases is a swipe at your bottom line. You are also working remotely, and IT can’t just stroll down a hallway for a visit. All of the help you’re going to get is via phone (or instant message if that is still working).

That also assumes your tech support is going to be a help. Maybe that won’t be the case. Who knows what bargain-basement service your telerad employer is using in the name of saving a few bucks? Even if the tech support is halfway decent, the first thing they’re going to do with you is go through a tedious series of troubleshooting steps you have heard way too many times before. Is everything plugged in? Turn everything off and on again, etc.

Wouldn’t it be nice if you, as the rad so heavily dependent on your workstation rig, had a decent chunk of the tech support person’s know-how? Maybe you could do your own troubleshooting, and only have to call for help 50 percent, even 25 percent as frequently. When you did wind up talking to tech support, you could begin by telling them everything you already did so they could cross that much off their checklist and skip ahead to whatever you hadn’t already investigated.

On top of that, perhaps you could tell him or her that your fellowship had you spend three-plus months in IT training on all of the stuff relevant to working in telerad. They wouldn’t have to take your word for it that you already confirmed that items A through M aren’t your issue, and to start with N. You would have a fellowship diploma to prove it! This may also be of interest to any prospective employers who might like to have your value-added skills in their workforce.

Fellows would, indeed, spend rotations of their fellowship hanging out with the IT people employed by (or contracted with) the telerad group. It would be part of IT’s job: Have the fellows shadow them, watching and learning whatever tech support was up to or routine maintenance stuff if things were running smoothly.

When there was nothing at all to be done, the IT folks could just sit with the fellows and give them a “what you need to know” practical education. It would be in the techies’ interest after all. A well-versed fellow could help them on the job and might one day be a more self-sufficient customer.

The other major type of rotation would, in fact, be practicing radiology. After all, it wouldn’t be all that helpful for a rad to graduate residency and then spend a year letting his interpretive skills get rusty.

This wouldn’t just be more of the same-old, same-old reading room routine. As I noted before, the fellowship should be in an actual teleradiology group. Well, seasoned telerads would be precisely who the fellows sit with, and the focus would be on seeing and assimilating the habits and skills that made those attendings successful telerads. The fellows would learn how to gain speed and efficiency without sacrificing accuracy.

In residency, speed is far from the goal. One is supposed to be learning the fundamentals of diagnostic radiology. One doesn’t rush things along while a resident is trying to grasp the basics or hurry on to the next case when there are still valuable teaching points on the last one.

A fellow planning on doing telerad needs to get his or her numbers up, and that’s not just about reading a lot of cases to gain experience and confidence (although that will happen in the process). Rather, the telerad attendings will show their fellows “how I do it.” That includes all of the tricks they have learned. This includes using keyboard shortcuts and voice commands, programming mouse buttons, arranging PACS toolbars, setting preferences, etc. Of course, this training would also include making the best use of all the tools offered by voice recognition software: macros within macros, templates, autocorrect features, etc.

Left to their own devices, new graduates going into telerad might take years to figure out all of this on their own. Even then, there might be tricks they have never encountered. A couple of decades in, they might feel too set in their ways to take on new habits. However, if you showcase all of this information while they’re still at the beginning of their careers, especially during rotations with a dozen different attendings who each have their own proven methods (and anecdotes to share from their previous telerad gigs complete with cautionary tales), you are giving the fellows access to a complete arsenal of “best practices.”

A teleradiology fellowship that offers an information technology (IT) component and dedicated time with teleradiology attendings to learn tricks of the trade with workstation navigation could go a long way toward reducing downtime and maximizing efficiency.

Exploring the Merits of a Teleradiology Fellowship, Part 2

A prospective teleradiologist recently posted on one of the social media outlets I prowl. Still in residency, he wanted to know what sort of fellowship, if any, would be valuable in that line of work since, as he put it, there aren’t any programs for telerad.

That last bit gave me a chuckle. Considering the lengths to which many academic types will go to carve out personal niches, why hasn’t anybody put forth a formal telerad fellowship? Surely, some entity would consider it worth the bragging rights if only to be the first one.

I could envision it. To properly train people for working in telerad, you would force them to work overnights, seven days on/seven days off, and constantly tell them to read more cases, faster, and with greater accuracy. Of course, they would need to “practice” the tele lifestyle by never actually physically showing up in your facility.

One of the funny things I have noticed over time is that if I think about how ridiculous/stupid/laughable an idea is, I can wind up taking it more seriously. It reminds me of a psychological experiment in which subjects were given the task of representing the opposite of their usual political views for a few weeks. Afterward, a surprising number of them reported that their views shifted as result of the play-acting.

(Editor’s note: For related articles, see “

Teleradiologist Overcalls and Hedging: We Are What You Make Us

Issues and Answers with Outsourced Teleradiology Night Coverage.

The more I thought about how absurd a telerad fellowship would be, the more I came to realize it could actually be a valuable experience, perhaps more so than some other radiology fellowships I have seen out there.

I won’t poke at any particular subspecialty or institution. Let’s just say that a lot of fellowships seem to be a matter of doing more of the work already done during four years of residency. Granted, additional experience is valuable, especially if the subspecialists in your fellowship are better than their counterparts wherever you did your residency program, but how often does a fellow really do or learn something that had not been doable/learnable during his earlier training?

By contrast, the telerad fellowship I imagined would have trainees doing things truly new to them in addition to getting well prepped for a subsequent career of remote radwork. The more I thought about it, the more convinced I became that it’s a matter of when, not if, such a program gets brought into being.

To really be worthwhile, the fellowship would have to be offered by an outfit that already had a robust telerad practice in place. This might be obvious to some. If you were considering subspecialty training in pediatrics or oncology, you might lean toward programs offered by Boston Children’s Hospital or Memorial Sloan-Kettering Cancer Center rather than taking your chances with Random Community Hospital in Anytown, USA.

It goes beyond that though. A lot of the issues and special challenges faced in telerad are often off the radar and even complete unknowns in traditional onsite practices. Literally everyone I’ve known who has gone into telerad, myself included, faced substantial learning curves for things that were foreign concepts when working onsite. Someone claiming to offer telerad fellowship training outside of an established telerad milieu would be at best misguided and arguably fraudulent.

One of the key elements of a telerad fellowship would be the teaching of its logistical aspects. That might get left to administrators and ancillary staff in a traditional, onsite practice. If things are less than streamlined and efficient, they might be annoying, but it is far from a deal killer.

A telerad group that wants to stay afloat can’t be so cavalier. If you misjudge your rad-to-work ratio one time too many, the places you are covering may lose faith in your ability to manage their volumes and kick you to the curb. Err in the opposite direction — too many rads routinely emptying the worklists and having nothing to do — and your workforce might get angry about not being able to hit their productivity targets.

Fellows would learn all about this stuff, and other things that a successful teleradiology service needs to get right in getting/keeping contracts for coverage. Vital concepts may include typical referrer expectations for turnaround times (TATs); how to predict case volumes at various times of the day/week/year, and accurately staff for the same; and addressing the vagaries of credentialing when you are covering multiple different facilities. In other words, there are “business aspects of radiology” that get mentioned but are rarely comprehensively covered during residency training.

Running a telerad group isn’t all about appeasing and managing expectations of the referrers. There is also plenty to be learned about recruiting, retaining, and otherwise managing the radiologists and ancillary staff on your team. Fellows would learn about relative value units (RVUs) as well as the pros and cons of various models for compensation (salaried, per-click, hybrid). One would also learn about the differences between 1099 and W-2, and how only some telerad situations allow a real choice between them.

Formal sessions to discuss these issues with the telerad group’s leadership could be augmented by routine communications as “learning opportunities” occurred. For instance, one could send an email to the fellows when an unexpected spike in case volume one night was either successfully handled by contingency plans established by the practice, or when such a spike created trouble due to a lack of safety net coverage.

That is far from all I’ve got for my teleradiology fellowship. Tune in next week for more.

Navigating key logistical aspects, maintaining coverage contracts, and understanding the pros and cons of different reimbursement models are just a few of the topics that could make a teleradiology fellowship worthwhile.