How to approach the first year in Radiology

How to approach the first year in Radiology

I received a lot of questions about books and requests for a guide on how to go about life as a PG-1 in Radio. Although I initially set out to write a guide to the first year of residency, I felt that I can’t do justice to a “guide”. I’ll leave that to more capable people but what I can do is give you guys a distillation of the things I wish I had done interspersed with mistakes I wish I had not made.

Much of what I am going to say is not going to apply to many of you because the post graduate programs in this country are not uniform with respect to duty hours, modalities, work load or even the attitude of your seniors but I am hoping most of you will find something useful in this!

As a first year, most residents primarily work with X-rays and ultrasounds with occasional forays into CT and MRI. Given the terrible exposure to radiology that we get in our undergraduate days, the first few weeks of residency are the most daunting, especially when you try to grapple with ultrasound.

Right at the beginning, I want most of you to understand something – No one is going to go out of their way to teach you the basics. You may get lucky and get a senior who is kind and likes to teach but even that senior is swamped with his own work and academics and as such, will not be as available as you wish. Secondly, and this may not apply to all departments, but I have seen that most residents (especially those in government colleges) complain that the academics in their department is not adequate. This is another fact that you are going to have to make your peace with because the principal responsibility of the professors and their department is maintenance of patient care service. Your academics comes second (or last!), sadly.

The primary reason why your seniors and professors want you to learn is not because they are benevolent people who care for your intellectual development, it is so that you can handle the workload thereby reducing their work. Of course, there are exceptions everywhere but that doesn’t change the norm.

There’s another truth that you must face right away – Academics. I don’t know why most of you have chosen radiology but now that you have, it will kick your ass. If you think this is a relaxing branch where you can chill in the AC, you would be right…but that’s certainly not during residency. In residency, this subject will behave like the pathogenesis of cystic fibrosis – You’ll have a faint idea about why things work the way they do but true comprehension comes much later!

The only way that things will be better for you is if you sit down with your books and read. Nowhere is the saying – Your eyes (literally) don’t see what your mind doesn’t know – more relevant than in radio-diagnosis. You have to know what you’re looking at to correctly diagnose what it is and what it is not. For that, you have to study. A lot. All of them ridiculously long subjects. Of special significance in your life will be good old anatomy. (Thank god, there’s not a lot of biochemistry!)

So, here’s hoping none of you are allergic to hard-core academics!

Coming to the first modality at hand – Ultrasound.
It is truly a monster during the first few days where most residents cannot differentiate the front end from the rear end. Here’s what I recommend that you do. Watch introductory YouTube videos and try reading the WHO manual before your try to pounce on the big fat standard texbook- Rumack. In your department, chances are you are not getting enough hands on because there are too many patients and your seniors don’t have enough time to hold your hand and walk you through every step. The best way to deal with this is by going to the department early (before official duty time) and start examining patients. Obviously, you won’t be releasing the reports without supervision, but you can get confirmation of your findings (or mistakes) when the patient gets a repeat examination by a senior. This is how I learnt and this is how most first years learn. I know how difficult it is to believe that you’ll ever diagnose anything in that doordarshan channel but trust me, it gets easier with time!

Most of us are oriented to X-rays but if you think you understand X-rays, oh boy, you’re in for a surprise. Other specialists and doctors may have a working knowledge of X-rays good enough for their practice, but as a radiologist you’ll be looking for things in that black and white film that you cannot even imagine right now. There are a couple of excellent books on Chest X-rays that you can start with – Felson’s and Chest X ray Survival Guide. You can check out these books and see which one suits you better.

If you’re in an institute where you get exposure to CT and MRI right at the onset, yay, more work for you! Try to understand the basic physics of CT and MR before you begin reporting because even though you can report without knowing the underlying physics, no one can deny that it helps. The standard textbooks that almost everyone uses are Osborne for Neuro-Rad and Haaga (I kid you not!) for whole body CT and MRI. You will have to be married to these books for the next three years in addition to extra marital affairs with several thicker and scarier books, should the need arise.

Radio-Physics is something that I really like talking about. Most people don’t like it. I have always found it fascinating and as a result, it has taken up a disproportionate amount of my time which I could have devoted to other pursuits but I have no regrets. Understanding the mechanisms of how things work is a truly satisfying way of learning about this subject.

In all of these modalities, the language of reporting is important. Not many people think this is very important but I have always been fascinated by reports that have a good language. There are certain reports that are so well written that you can visualize the lesion in your head – much like a 3D CT reconstruction! The art of describing a lesion is a skill that not many are blessed with. It is not something that anyone is born with. The more effort you put into it, the better you get at it.

Another important aspect is Intervention. Again, this varies from center to center but it is very important that you find the middle ground between “scared out of your wits” and “stupidly aggressive”. Always perform your first few interventions under supervision. Never think that “nothing bad will happen” because Murphy’s law says anything bad that can happen will happen so it is in your (and the patient’s) interest to always have a solid back-up plan. Things can go south really fast if you poke around inside a human body with a sharp instrument while squinting at your monitor without seeing anything. Identify the senior who is good at interventions (because not everyone is) and try to get as much training under him or her as possible because no one will teach you after residency.

Do not be afraid of mistakes. In fact, I think everyone should make mistakes as long as you know that you will be supervised. I understand that it is not always possible but wherever it is, volunteer and take risks so that you make catastrophic, embarrassing mistakes that your professors and seniors can then rectify. Everyone is waiting for you to make a mistake – the people in your department and even more importantly, the people in other departments. They are waiting for an opportunity to pounce on you. It’s a very professional world out there but, and I cannot stress this enough, making mistakes (in a safe environment without jeopardising the patient care) is the fastest way to learn. If you won’t learn through your mistake, the taunts and insults certainly will make you learn. Never shy away from throwing a weird diagnosis out there because if you’re wrong, then you’ll be laughed at and you’ll get the opportunity to know why you’re wrong. And if you’re right, well, you’re the boss!

Always ask questions relentlessly. Unsurprisingly, that’s the best way to get answers! The bonus, however, is that you often get unexpected gyan in addition to the expected answers. I can confidently say that I have learnt the most during discussions with me seniors at work. Don’t be disappointed if you’re not learning massively every day or if your department has poor acads. The way this works is you keep getting scattered information everyday from different sources but if you’re careful and attentive, all the information percolates into your memory and you do end up learning in the end!

Lastly, remember that if you’re the smartest guy in the room, you’re in the wrong room (I knew this even before I watched kota factory!) Always seek greater challenges. Always compare yourself to someone who is MUCH better than you. It is okay if you always feel shitty about that – you’re motivated and learning. The alternative is feeling complacent about your position as the king of ants. That is probably the biggest mistake you can make during a period like residency when you are supposed to evolve every day.

Stay hungry and good luck!

PS: Don’t forget to correlate clinically.