Mysteries of the Dark Room
Stefan Tarnawsky Sep 26, 2018
As the fervor of Residency applications heats up, I wonder: how do I stand out in the sea of applicants? Which unique features of IUSM might give me a leg up on students from other schools? Both Geriatric and Critical Care are required core clerkships at certain schools. What is unique about IUSM?
Our core clerkship in Radiology is one such unique experience. Imaging, after all, is pervasive in medicine. You’d be hard pressed to lie down in a hospital bed without getting a CXR, head CT, or abdominal ultrasound. Further, radiology techniques are rapidly evolving. Old tests (eg: 131-Iodine uptake with 2D pinhole imaging) are likely to be replaced with more sophisticated methods (eg: 3D SPECT). This will not only render all current Step2 questions obsolete, it will also challenge practicing physicians to stay current.
I was apprehensive starting my Radiology Clerkship. My most recent classroom-based course was 5 years ago, when I transitioned from MS2 to the Graduate School phase of the MSTP. Since then, I’ve grown fond of patient-centered learning. How would I cope when I was plucked from the wards and placed in a lecture hall? Would I be able to stay awake? I worried that I would be too antsy to get anything meaningful out of the course.
I need not have worried.
Radiology lectures are like an Agatha Christie mystery novel. The story begins with character introductions (Xray, MRI) with vivid descriptions of their personalities (techniques, advantages, disadvantages, etc). Then you meet your hero/heroine (normal patients) and see representative images of healthy controls. Finally, the whodunit begins. Image after image shows clues (abnormalities) that you—as the detective (audience member) — are to use to solve the mystery.
The faculty made their lectures educational and fun. Initially, it was a challenge simply to identify the pathology. As one gets comfortable distinguishing normal and abnormal, one begins to tell a story about the image: guessing as to why the patient has the observed findings. For instance, at the start of the course, the goal may be to identify cardiomegaly. But as the course progresses, you not only start to build a differential (effusion, CHF, cardiomyopathy, HTN…), you also start to use the patient history (healthy 6mo) to narrow the diagnosis (congenital problem vs non-accidental trauma) and state what further testing could distinguish these possibilities (TTE, NCHCT).
Before starting the clerkship, I imagined radiologists to be solely experts at identifying abnormalities on imaging. Not so. My faculty also had an inspiring broad knowledge of pathophysiology. The most poignant example was my faculty predicting the presence of a lung cancer having only seen a lower extremity X-ray that showed periosteal changes consistent with hypertrophic pulmonary osteoarthropathy When the cancer was subsequently found by CXR, it felt like I had witnessed magic.
I count myself fortunate to be an MS4 in
the last year that Radiology is a required clerkship at IUSM. In subsequent years it will be an elective. I suspect it will remain popular given the pervasiveness of imaging tests in hospitals and the need for all interns to be familiar with them. I wonder, however, whether it would be been feasible reintroduce Radiology as a required clerkship by trimming it to 2 weeks? Thereby, it could be taught to MS3s during the same month as their 2wk anesthesia rotation and better prepare us for the Medicine and Surgery clerkships. After all, IUSM should take advantage of its size to provide its students with unique opportunities, not only to demonstrate the breadth of medical practice but also to distinguish its graduates from those at other MD programs.
Great news IUSM! In future years, Radiology will remain a required elective! During MS4 it will be shortened to 2 weeks with additional preliminary Radiology training between Phases 1 & 2. It’s as though the Administration read my blog and followed my recommendation. (or your intrepid blogger was misinformed and now stands corrected.) Either way, it’s excellent news for IUSM students!