Elements Of A Strong Radiology Residency Program

[W0lfgang]

On my carms tour, I felt a bit lost as to what to look for to help my rank order list. Here are a few features to look for in what I think a strong residency program should offer.

 

1.  Resident group cohesiveness.  Do they seem happy? Are they a collegial group?  How they treat each other could predict how you'd be treated.

 

2.  Royal College success rate. How many people failed in the last 10 years or so? Remember to consider how large the program is. A program with 5 residents per year and 1 failure in the last 10 years is not necessarily worse than a program with 2 residents per year and a perfect royal college record.

 

2a. On a related note, ask how many mock oral exams the pgy-5's get each year. The more the better! 

 

3.  How does call work?  Call shifts are amazing learning opportunities.  The cases I see on call are significant conributors to my overall knowledgebase and skillset.  Call is when I get to practice being an indepedent radiologist with the luxury of someone else catching my misses.  In my opinion, you should look for programs that offer:

  1) call WITHOUT in-house fellows/staff (they are a phone-call away), ie you're more independent.

  2) Moderate case volumes (30+ cases). If too few, you're not exposed to enough.

  3) NO reviewing after your shift is over. You want to go home asap, not review with a staff until 11am on your post-call day. You can look up your cases later and see what you missed.

  4) Shifts are not too frequent.

 

4.  How successful are past graduates in landing desired fellowships or community jobs?

 

5.  Large catchment area.  Will you be exposed to enough pathology?

 

6.  Does the program director care about the residents?

 

7.  Is there an optimal mix of rounds and daily workloads?

 

 

This my personal list after a few years in residency.

[W0lfgang]

8.  Optimal ratio of fellows-to-residents.  Too many fellows means they're taking away your cases. Some programs are fellows-centric, while others are residents-centric.  I recommend the residents-centric programs.

[Dermviser]

Great list - I imagine this runs true for many other specialties as well.

[geraldthegorilla]

Hi there,

 

Great post re: what to look for in a residency.  I'm currently part way through my rads residency here in Canada and I'd add the following:

 

1.  Resident group cohesiveness.  Do they seem happy? Are they a collegial group?  How they treat each other could predict how you'd be treated.  

This is a very good leading indicator.  During the interview social ask the residents how they feel about the program.  Bear in mind, however, that the residents who attend any peri-interview socials may be those who are most/more enthused about their program.

 

2a. On a related note, ask how many mock oral exams the pgy-5's get each year. The more the better! 

Very much agreed.  Ask about the structure for the Royal College exam prep.  For example, at what point during PGY-5 are the residents relieved from call?  Is there a structured evening lecture program offered by the staff.  (Within my program, there is.)  Are there many staff who are current Royal College examiners who will review with you during PGY-5?

 

4.  How successful are past graduates in landing desired fellowships or community jobs?

Hmmmm.  This is highly variable and very much dependent on the fellowships chosen by the residents as well as the residents' capabilities and choosiness re: jobs.

 

6.  Does the program director care about the residents?

A very, very important factor.

 

7.  Is there an optimal mix of rounds and daily workloads?

Great question, and even more specifically, how high is the quality of the weekly rounds offered.

 

All the best,

GtG

[Lactic Folly]

2a. On a related note, ask how many mock oral exams the pgy-5's get each year. The more the better! 

Very much agreed.  

 

A very commonly held attitude.. though I'd postulate there are diminishing returns after a certain point (~30-40 should you be lucky to have that many), due to increased time spent travelling instead of studying, and coming in early / staying late to accommodate staff workdays. I'd be comfortable with 15 as a minimum. The number of mock orals may serve more as a surrogate of faculty:resident ratio and faculty engagement.

 

Otherwise the above lists are good. I'd also add whether the residents read out during their rotations with staff who are specialized in those areas (so you pick up the nuances); whether graduates have a decent foundation in every area for going into general community practice (no glaring deficiencies - this becomes more salient once entering practice); whether there is sufficient hands-on experience in procedures (though one can improve diagnostic competency through self-study to some extent, improving skills such as ultrasound, fluoro, biopsy, etc. really takes some expert guidance).

[W0lfgang]

9. Did any residents LEAVE the program in recent years?

 

Programs will lose residents from time to time for various reasons, which shouldn't be cause for alarm. However, programs that have lost 2 or more residents could be harboring some serious problems. I know of one such program but I don't know why they left or if there are in fact any problems, but it does make me question whether the remaining residents are happy there.

[JohnGrisham]

9. Did any residents LEAVE the program in recent years?

 

Programs will lose residents from time to time for various reasons, which shouldn't be cause for alarm. However, programs that have lost 2 or more residents could be harboring some serious problems. I know of one such program but I don't know why they left or if there are in fact any problems, but it does make me question whether the remaining residents are happy there.

As a general thought, if a program lost 2 residents, and it was already a small program - wouldn't the workload of the remaining residents increase? 

 

Or is that a wrong assumption.

[rmorelan]

As a general thought, if a program lost 2 residents, and it was already a small program - wouldn't the workload of the remaining residents increase? 

 

Or is that a wrong assumption.

 

yes it will increase - call is covered by the residents the no matter what - lose a resident and you get more call. Even if the reason for leaving is good - and it often is - that still doesn't mean it doesn't suck (speaking from experience )

[ploughboy]

I'm definitely no radiologist, but here are my thoughts about residency programs:

 

2a - agree that total number of mock orals is a good indicator, but the type and organization of them is likely a better predictor.  You don't need more than 25 or 30 to figure out "examsmanship" etc.  Diminishing and even negative returns after that.  You want to get a sense that the program is providing support for this as a proxy for other ways that they will support their residents.

 

You also want to be examined by the right people.  You want to be examined by recent grads, and people who have been Royal College examiners within the last few years.  That will be the most representative, and highest yield. 

 

Having mock exams from other people can actually be counter-productive (eg the head of my provinces' poison control centre gave me an oral exam once.  She's super-qualified, is a great clinician and I like her as a person, but she sat the Royal College exams 25 years ago and hasn't been involved with the examination process for at least a decade.  I don't think she realized that the times have changed, as has the exam format.  So I got pimped about esoterica for 20 minutes, which was exactly what I *didn't* need 5 weeks before sitting my Royal College exams.  Despite having my spirits broken, I did ok on the real thing.)

 

 

6.  You need to talk to as many program directors as you can.  I think it's actually kind of funny how med students view "meeting with the program director" as a chance to sell themselves and be remembered, without realizing that it is a two-way street.   When you meet with a PD, you need to get a sense of what (s)he is like as well.  If (s)he comes across as a completely disengaged jerk when meeting with you as medical student, then that is likely to continue when you are a resident and might be even worse(1). 

 

On the other hand, if you feel they are genuine in their interactions with you and that they are the type of person who is concerned about your education, well-being and future plans, that likely bodes well.  Remember, this person is going to be incredibly important for the next 5 years of your life and even beyond that depending what your career aspirations are.   You don't have to *like* your program director, but you have to be satisfied that (s)he supports you.

 

Ask yourself: Can I spend 5 years with this person as my boss?

 

 

Good luck, all...

 

 

(1) exceptions exist, of course.  I know docs who totally blow off meetings with medical students because they view them as unimportant and irrelevant.  But once you are a resident/fellow, and are "one of the tribe", they will go to the wall on your behalf.  Membership does indeed have its privileges.

 

 

 

On my carms tour, I felt a bit lost as to what to look for to help my rank order list. Here are a few features to look for in what I think a strong residency program should offer.

 

1.  Resident group cohesiveness.  Do they seem happy? Are they a collegial group?  How they treat each other could predict how you'd be treated.

 

2.  Royal College success rate. How many people failed in the last 10 years or so? Remember to consider how large the program is. A program with 5 residents per year and 1 failure in the last 10 years is not necessarily worse than a program with 2 residents per year and a perfect royal college record.

 

2a. On a related note, ask how many mock oral exams the pgy-5's get each year. The more the better! 

 

3.  How does call work?  Call shifts are amazing learning opportunities.  The cases I see on call are significant conributors to my overall knowledgebase and skillset.  Call is when I get to practice being an indepedent radiologist with the luxury of someone else catching my misses.  In my opinion, you should look for programs that offer:

  1) call WITHOUT in-house fellows/staff (they are a phone-call away), ie you're more independent.

  2) Moderate case volumes (30+ cases). If too few, you're not exposed to enough.

  3) NO reviewing after your shift is over. You want to go home asap, not review with a staff until 11am on your post-call day. You can look up your cases later and see what you missed.

  4) Shifts are not too frequent.

 

4.  How successful are past graduates in landing desired fellowships or community jobs?

 

5.  Large catchment area.  Will you be exposed to enough pathology?

 

6.  Does the program director care about the residents?

 

7.  Is there an optimal mix of rounds and daily workloads?

 

 

This my personal list after a few years in residency.

[Lactic Folly]

 

Ask yourself: Can I spend 5 years with this person as my boss?

 

 

Good luck, all...

 

 

(1) exceptions exist, of course.  I know docs who totally blow off meetings with medical students because they view them as unimportant and irrelevant.  But once you are a resident/fellow, and are "one of the tribe", they will go to the wall on your behalf.  Membership does indeed have its privileges.

 

Supportiveness of the PD would be a good thing to ask the residents about, in case you can't get a good feel from a one-off meeting.

You might also ask how long the current PD has been in this role, as there may be plans underway to pass the baton and you could end up with a new program director by the time you are a junior resident.

[geraldthegorilla]

Ploughboy, it's been a while.    Great to see that you're still here.

 

Regarding the advice re: mock orals and staff who are currently, or were recently, Royal College examiners, I'd agree.  Within my program we have numerous staff radiologists who are current Royal College examiners.  In general, their approach to rounds is quite different from those of other staff.  They tend to grill you as they might a radiology examinee, which is really amazingly valuable.  That is, most will present an initial set of images as well as a brief history.  Then you are on your own to walk through the case.  You may ask for additional imaging and the staff will ask you questions as you proceed, relating to any aspect of that case, i.e., physics of the imaging, epidemiology, pathophysiology, management, etc.  These can be intense and thoroughly rewarding experiences.  Therefore, although having Royal College examiners on staff is great for mock orals in PGY-5, there are other fringe benefits throughout the other years of residency.

 

Cheers, 

GtG

 

 

I'm definitely no radiologist, but here are my thoughts about residency programs:

 

2a - agree that total number of mock orals is a good indicator, but the type and organization of them is likely a better predictor.  You don't need more than 25 or 30 to figure out "examsmanship" etc.  Diminishing and even negative returns after that.  You want to get a sense that the program is providing support for this as a proxy for other ways that they will support their residents.

 

You also want to be examined by the right people.  You want to be examined by recent grads, and people who have been Royal College examiners within the last few years.  That will be the most representative, and highest yield. 

 

Having mock exams from other people can actually be counter-productive (eg the head of my provinces' poison control centre gave me an oral exam once.  She's super-qualified, is a great clinician and I like her as a person, but she sat the Royal College exams 25 years ago and hasn't been involved with the examination process for at least a decade.  I don't think she realized that the times have changed, as has the exam format.  So I got pimped about esoterica for 20 minutes, which was exactly what I *didn't* need 5 weeks before sitting my Royal College exams.  Despite having my spirits broken, I did ok on the real thing.)

 

 

6.  You need to talk to as many program directors as you can.  I think it's actually kind of funny how med students view "meeting with the program director" as a chance to sell themselves and be remembered, without realizing that it is a two-way street.   When you meet with a PD, you need to get a sense of what (s)he is like as well.  If (s)he comes across as a completely disengaged jerk when meeting with you as medical student, then that is likely to continue when you are a resident and might be even worse(1). 

 

On the other hand, if you feel they are genuine in their interactions with you and that they are the type of person who is concerned about your education, well-being and future plans, that likely bodes well.  Remember, this person is going to be incredibly important for the next 5 years of your life and even beyond that depending what your career aspirations are.   You don't have to *like* your program director, but you have to be satisfied that (s)he supports you.

 

Ask yourself: Can I spend 5 years with this person as my boss?

 

 

Good luck, all...

 

 

(1) exceptions exist, of course.  I know docs who totally blow off meetings with medical students because they view them as unimportant and irrelevant.  But once you are a resident/fellow, and are "one of the tribe", they will go to the wall on your behalf.  Membership does indeed have its privileges.

[schmitty]

Is anybody willing to give some insight into which programs in Canada they rank the highest and why? 

[W0lfgang]

You may have to wait until after the ROL deadline, when things are locked in. 

[rmorelan]

You may have to wait until after the ROL deadline, when things are locked in.

 

Ha very good point - carms algorithm and all that

[radiologyhopeful]

I'll speak to what I think constitutes a strong Radiology residency program. I'm a Canadian trained, board certified radiologist and I can give you a real- life perspective on what makes the best programs, having been through one myself recently and working at a different, larger center now. I think some of the points that have been brought up are good, most are well emphasized and some are under emphasized. Here's my two cents and stuff I wish someone had told me before I started:

 

Size: Aim for a medium sized program in a decently sized city. Residency should be a general experience where you get exposure to a reasonable level of complexity which is reported by well rounded general radiologists. There's a perception in the academic mega center of this country (you know what it's called) that everyone needs 2 fellowships from fancy American schools to read an abdominopelvic MRI or a chest CT. That's not what you want to be surrounded by in residency. Believe me, that's a disaster to be around on so many levels. That's what fellowship is for (should you choose it) and even then, it's over blown sometimes. In a medium sized program, you get some exposure to the sub-specialization, but you also get the general stuff. The general stuff is what residents need to worry about (i can't emphasize that enough!) because the exam and real life practice (for most of us) is general!

 

Fellows: This should be a major red flag for everyone of you. In some places there are lots of fellows and sometimes they are equal to in number, or even out number the residents. Again, this is the case at the largest program in the country. This has the very unfortunate effect of severely diluting the learning experience for residents. Day time clinical service is exclusively by fellows and not residents This is the whole point of residency!! In my current capacity I have seen junior residents in this environemnt reporting 3 or 4 CT cases a day because the fellows do the rest of the work and the residents are often off at rounds. There's is no pressure on the residents and the general perception they do little to begin with.

 

Rounds: This is important. You want rounds for so many reasons and you want them to be good. Ask exactly how they are scheduled and whether they actually happen. The biggest alarm should be the number of rounds per day. This might sound crazy, but 2 or 3 hours of rounds everyday is way too much. That is robbing you of time at the work station. If you are in spot with lots of rounds and lots of fellows you will be getting hit really hard with a really diluted learning experience. You have to learn how to handle volume, be efficient and be decisive. You can't learn this unless you are in the hotseat seeing cases.

 

Call: I like alot how Wolfgang explained call. His assessment is totally accurate. If you want to keep your doors open for after residency (which you all should) you need to come into residency with the mindset that "I want to learn how to work". The volume in the real world is very challenging, even for the strongest rads. You build your skill set when you're a resident doing call. I was always so proud of the way our  resident ground did call (no staff in house, no fellows in house, just good old fashioned resident call) because we owned those calls and they were ours to learn from in every possible way. Were there stressful nights, arguments, etc? You betcha! but thats life and if you don't want to work hard and efficiently, you won't make it in this field. You can come out of residency having done alarmingly little case work in some programs and pass the exam with flying colours. That means literally nothing in the real world. You have to be able to handle case volume and do a good job at it. Aim for a program that has a mix of support on call, but still lots of resident independence. Be aware, these are not things you will typically find in the largest programs.

 

Catchment area: I wouldn't worry about this too much. There's enough pathology in general. I would argue that the residents in the largest programs with the largest catchment areas are actually seeing less pathology for some of the reasons I outlined above.

 

Mock orals: I did 12-14 mock orals and that was more than enough. My program has one of the best track records of FRCPC success in the country, hands down. People go bonkers about the exam and sadly residency (especially at some places) has evolved into 4 years of worrying and preparing for the exam. This comes at the expense of residents who literally do not know how to work, but only think about how to pass exams. I see this everyday and its very sad. In my current work, I'm hearing of residents who are aiming for 20-30 mock orals. That's completely ridiculous, over the top and it doesn't come without expense. The expense is that these guys/girls are away from the work station, away from protocoling, away from procedures because they are so damn worried about the FRCPC exam. It would be an asset if your program had some old or current examiners and a good number of recent CANADIAN TRAINED grads who have sat the exams. They give the best mocks. Thats what you should look for.

 

Culture of the group: This is pretty key to wrap your head around. You have to fit in with the group to be happy for 4 years. If you are surrounded by a bunch of nerds who just want to talk about papers / research / publications and you aren't that kind of person, you wont enjoy your residency as much. Similarly, if you have massive academic aspirations (which i don't think any resident should have out of the gate), then you will probably not like programs where the journal club gets cancelled and rescheduled as a pub crawl regularly. Ask about social events, christmas parties, etc. to know what these residents get up to. How many people have kids? Is that sort of thing supported, etc. Small and medium sized programs are going to be the closest knit. The social fabric of the year you are in will be majorly important when it comes to studying, case review, sharing resources in your final year before the exam.

 

Residency director / RPC: This is so tough because this can change at the drop of a hat. I honestly think that at the interview you have to suss this out yourself. Ploughboy gave excellent advice about this above. When you are in that station with the PD try to get a vibe from that person. Ask them questions, fell them out. Do they seem warm, approachable, reasonable? Are they an arrogant prick? Go with your gut on this one. You can all judge character and even though the idea is for them to interview you, don't be shy to ask the PD some questions and see what you think. It's 100% a 2-way street. If you get the sense they'd throw you under the bus whenever they could, they probably would in the actual residency... Sadly, not everyone in the medical field / medical education is in it for the right reasons.

 

Electives: This is really important for networking. In my program, we had 1 month of community elective time at the end of PGY4. This was very flexible. Some people went abroad, some went to local clinics, others left the city and went to other communities in other provinces. Having flexibility here is really important because this may be your earliest opportunity to go somewhere, meet a group and network. I was alarmed to learn about the largest program in the country restricting their residents and not allowing them to go where they choose on this block. That should be a major red flag. Networking is so important and especially if you are an out of towner, you will want this flexibility.

 

Good luck with your rankings. Keep an open mind. We are so fortunate to live in a great country with many strong programs. Don't be afraid to branch out and try somewhere new. The strongest people are often not from the programs you expect (based on the way some of their residents carry themselves). Enjoy the whole process, you're all talented. Just be normal and work hard. It will all turn out.

[Lactic Folly]

Rounds: This is important. You want rounds for so many reasons and you want them to be good. Ask exactly how they are scheduled and whether they actually happen. The biggest alarm should be the number of rounds per day. This might sound crazy, but 2 or 3 hours of rounds everyday is way too much. 

 

I agree with most of the above post, but I can't concur that 2-3 hrs of rounds is a red flag in itself. For example, given 7-9 am and 12-1 pm rounds, a resident can still pick up and review a very healthy amount of cases from 9-12 and 1-6 pm (that's still 8 hrs at the workstation). I agree that case exposure is important, but it's affected by factors other than just the number of rounds per day (such as fellows, culture, etc. as alluded to above).

 

The best rounds distill the best cases, pearls, and pitfalls from the accumulated experience of a staff radiologist in their area of expertise. The amount of ground covered in one hour can be huge, exposing you to topics you might not regularly encounter during the workday. In comparison, if you are doing a general-type list during the workday, even with high volumes, as a more senior resident you might only walk away with one or two cases/day that taught you something new.

 

I've spoken to residents from programs low in scheduled teaching rounds -- they ended up going to much more review courses than average.

[W0lfgang]

Thanks for your insight radiologyhopeful!