My interest in radiology began, as it does for many, with the thrill of coming to a solution based on imaging and some sparse words on a patient’s chief complaint. Reading radiologic scans is like learning a language — a code composed of axial and coronal views, enhancing and nonenhancing areas and anatomical landmarks. When you dive into the millimeter slices of a contrast CT and the defect snaps to your attention, you are hooked.
Something grabbed me on my third day in the radiology department. A CT of the abdomen and pelvis with enhancement in the right renal vein but not the left. Renal vein thrombosis. I picked up on a few other features from the scan, noting calcifications in the aorta that suggested the patient was middle-aged. Everything else was normal, and in that sense, anonymous. Then, I noticed something odd. The patient’s right iliacus and psoas were much larger than the left on coronal view. Who was this patient?
I went to meet him.
JJ was a retired classical musician and grandad. Eight years ago, he had an anterior cerebral artery stroke producing hemiplegia of his right leg. JJ was unable to plantarflex his right foot. Consequently, with each stride, he flexed the leg at both the hip and knee to clear the ground. He told me his right leg was indeed larger than his left. I sat in the visitor chair, and he told me a story of both frustration and hope. His strong right leg was a testament to months of rehabilitation that had indeed allowed him to walk again, to play with his grandkids again.
I worked for years with stroke patients, first in my biomechanics courses and then during two internships in motor rehabilitation laboratories during college. I also worked on making sports accessible for individuals with all kinds of disabilities, identifying barriers to entry to sport in this vulnerable population. The independence it fosters is vital to the well-being of anyone who has felt, at one time or another, in some way limited by their bodies.
Because of these experiences, I knew how much it hurt JJ to be bedbound again — eye-level with the walking frame he was proud to have never needed before. He was ill. But the radiologist had just handed over an important diagnostic clue which could get him up and walking again: his pain was from a renal vein thrombosis. After anticoagulation and fluid resuscitation, he could go back to the new normal he had achieved since the stroke. I want to take on such a role. But would it be enough to simply deliver reports without meeting the people I serve?
There are a few important things medical students should know about radiology. The first is that you do not have to meet the subject of a scan, which is something that was familiar to me before my time in the radiology department. The second is that you can meet them if you choose to. The third is that whether you have an exchange with your patient or not, your objective is still a human one, no matter how remote imaging may seem from the bedside.
What qualities do good radiologists demonstrate? I spoke with some radiologists to get their takes on this topic:
“Have a good attitude toward learning and bettering yourself.” –AMC
“Be enthusiastic and willing to put your time in.” –CO
“Communicators and diagnosticians.” –MMT
After more than twenty conversations with radiologists to this effect, I am beginning to fully appreciate the intricacies behind each answer to this question.
It is vital to acknowledge that radiologists are not dealing with information so much as they are dealing with patients’ lives. In the canonical case of a pulmonary embolism or tension pneumothorax, you have a duty of care to ensure that the patient is being treated emergently. You call their clinician. You spur that process into action.
There are other instances, as with JJ, where there is no physician to call emergently. However, that does not make the experience of reading such images any less human. Let us do a thought experiment. If one identifies a filling defect in the renal vasculature, then the next step would be to remove the obstruction. If A, then B. This appeals to those who, like me, studied logic or critical reasoning in college.
But there is much more: a testament to a man’s lived experiences, stamped for us in black-and-white. Here are his hip flexors. See how hard he works to have a normal life after his stroke? Self-sufficiency is important to him. Perhaps he is a caretaker to someone else. Perhaps he still lives on the second floor of the house his father built in Ireland and prides himself on being able to climb those stairs without assistance. Indeed, all of these things are true about JJ.
Incidental findings awakened my curiosity and, in so doing, interrupted the satisfying cycle of solving puzzles to bring me sharply into the human side of what radiologists do. I appreciate this every time I read a radiology report on my core clerkships. For many teams in direct patient care, the radiology report is the key — the piece of information that makes a care plan definitive or demonstrates that the plan is working or needs to be adjusted. It is the patient’s ticket to the best possible care.
Producing rapid, precision reporting is something radiologists should strive for. If you enjoy this process of honing a skill to your limit, you will thrive in radiology. But the radiologists I have met have shown me that the process of becoming a good radiologist begins with exposure to patient care. If you aspire to be the best that you can be, you cannot simply refine your understanding of pathological signs and gain familiarity with the imaging modalities and their limitations. You must also know what the clinician needs and how to communicate your findings most effectively for informing clinical care. The best experience in this regard is meeting patients and working with clinical teams. Several radiologists I have interviewed echoed the same.
I have had somewhat unique opportunities to work with clinical teams. My medical school consists of three years on the wards. With minor interruptions owing to the COVID-19 pandemic, I have experienced radiology, general surgery, gerontology, internal medicine, dermatologic surgery and orthopedic surgery. This year, I will participate in primary care, obstetrics and gynecology, psychiatry, pediatrics and neonatology, along with electives. Next year, there will be more. Being a part of so many medical teams has opened my eyes to the superior interprofessional communication an aspiring radiologist should strive to exhibit. What’s more, the experience has given me a first look at the clinical decision-making occurring after the teams have read the radiology report.
Regardless of the duration of your clinical exposures, I urge medical students to experience them as fully as you possibly can. Whenever possible in your core clerkships, own the clinical side of practice. Who knows? Patient care might turn out to be what you sought all along in addition to the excitement of reading a scan. There is a place for increased humanism in radiology, as I have learned from experiences like those with JJ.
Another important piece of successfully entering the field of radiology is meeting a mentor:
“Mentors guide you to be who you are meant to be, to do what you’re good at, to be where you should be.” –SB
The radiologists that I have met have introduced me to just how versatile radiology can be as a specialty. For example, they helped me to see that radiologists can play a more longitudinal role in a patient’s life. There are areas such as women’s imaging and some interventional oncology/interventional radiology where you develop such long-term relationships. Additionally, radiologists work in a broad spectrum of environments where expectations and care prognosis can vastly differ. Musculoskeletal imaging serves mostly healthy patients, while oncology sees people who are often going through the most difficult times of their lives.
Furthermore, there is aid work and volunteerism in radiology. You can volunteer at home or abroad, teaching others how to build sustainable radiology practices. But more than anything, start now. Take the extra few minutes to meet your patients now and really assign meaning to the work you will do in radiology. Because in your intern year, you will not have the luxury. Things speed up, as one radiologist said to me. Get things done quickly, but don’t hurry: take a long history from your patient and follow up a case.
What can medical students gather from all this? Look beyond radiology’s stereotype of the lone physician reading scans in the dark. Radiology is, in fact, for the people-person. Radiology information flow depends on radiologists being strong interprofessional communicators. Patient portals have initiated a growth towards delivering reports directly to the patient. Radiologists as communicators and advocates can also influence patient care on a larger scale. Significantly, clinically oriented radiologists can be the strongest advocates for patient care and can engender systems-level reform. Lung cancer screening in the United States is owed to several radiologist-led research efforts that collectively demonstrated its utility. Hopefully, lung cancer screening measures will soon be brought to Ireland, where a formal screening program is not yet in place, through similar initiatives.
A final thing you should consider about radiology is the gender gap. Only twenty seven percent of radiologists are women. I have had several conversations with female and male radiologists about the discrepancy, and I hope to participate in more as I progress in my career. Look to mentors and women who have found their way in the field, as well as peers around. Professional organizations like the American Association for Women in Radiology can help connect you to networking resources.
In short, being a radiologist is about being an interprofessional collaborator and an advocate for your patients. It is for those who enjoy both patient and cross-disciplinary contact. The patient narrative is paramount and radiologists should always focus on clinical relevance in reporting. Begin early, by connecting with patients and exploring what it means to be a part of the care team, so in future you may do the best radiology work you can.
Author’s note: To preserve the anonymity of those referenced in this piece, no names were used. In lieu of names, initials were used and these initials do not reflect those of real patients. Thanks to Dr. Anne Marie Cahill, Dr. Cathal O’Leary, Dr. Michelle Miller-Thomas, Dr. Sadaf Bhutta and all other guests who came on the podcast to share their words of wisdom.
Image credit: First Class Health Care in Panama (CC BY-NC 2.0) by thinkpanama
Columnist
School of Medicine at Trinity College Dublin
Fiona Doolan is a 4th year medical student at the School of Medicine at Trinity College Dublin, Dublin, Ireland, graduating in 2023. She holds a B.S. in physiology from Boston University, 2017. She is host of the podcast CXR: Careers x Radiology. CXR is a long-form interview podcast introducing radiology to the medical student. It was inspired by the explosion in virtual connectedness worldwide during the pandemic, and from a deep curiosity about the specialty. Fiona is an avid runner and aspiring radiologist.
Write Rx
Now and for the foreseeable future, providers and patients wear masks. An essential element of the doctor-patient relationship – nonverbal expression – is much reduced. When what is on our faces is anathema, we rely more heavily on narratives. Consider each entry of ‘Write Rx’ a prescription for a narrative medicine exercise that just might help you find the right words to relate to patients in this changed space. Here I hope you will find a bit of inspiration for reflection amidst the rigors of medical school, not in the least thanks to some famous physician-writers, excerpts from whom serve as an entry point for each exercise.