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Hello, and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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You can access the recording of today's conference

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and previous noon conferences by creating a free account.

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Today we are honored to welcome Dr. Long Tu

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for a lecture entitled, how

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to Be a Faster Radiologist While Maintaining Accuracy.

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Dr. Tu is a health services researcher,

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emergency radiologist,

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and neuroradiologist at Yale School of Medicine.

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Dr. Tu directs a multidisciplinary research group

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that works on stroke imaging, workflow optimization,

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and medical education,

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and is the author of several leading texts in diagnostic

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imaging, including How to Be More Efficient Radiologist,

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A Guide to Practice Reporting and Workflow Optimization.

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At the end of the lecture, please join Dr.

1:00

Tu in a q and a session

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where he will address questions you may

1:03

have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Tu, please take it from here.

1:17

Hi everyone. Thanks for logging in,

1:18

um, and for your interest.

1:20

I'm coming to you from my, uh, home office here,

1:23

and, uh, here we're gonna spend a little bit less than an

1:25

hour to talk about this topic, how

1:27

to be a Faster Radiologist while maintaining accuracy.

1:30

Okay. Um, so big picture,

1:32

this is like a really important topic

1:35

or focus that you, you know, for people in the later stages

1:38

of their training or the early part of attending Hood.

1:41

Um, it can be an often underappreciated

1:45

set of skills to develop.

1:46

Um, and I found that it has a huge impact on the happiness

1:51

of radiologists, their ability to collaborate well

1:55

with their group, um,

1:57

and, you know, their productivity, their ability to attend

2:01

to other commitments.

2:02

And so, um, this increasingly became an interest, uh,

2:05

to me a couple years ago as I saw the trend

2:07

of it being a major, uh, influence, uh, point of, uh,

2:11

or factor, um, in people's experience, uh, physician,

2:14

physician experience, unhappiness.

2:16

And so I dove into this

2:18

and I've, um, been developing

2:21

and helping, trying to help disseminate some

2:23

of the skill sets around, around this topic.

2:25

All right. So, uh,

2:27

and, uh, so without, you know, uh,

2:28

so we we're gonna dive into this

2:30

and I, I should disclose that I'm, you know,

2:32

I received full royalties from a number of books including,

2:35

uh, that text How to Be a More Efficient Radiologist,

2:38

and quite a bit of this content draws on and expands on,

2:41

or is in parallel to material in that book.

2:44

Okay? Okay. Here's kind of the outline of my talk.

2:49

We're gonna talk a little bit about the, uh, benefits

2:52

of developing efficiency

2:54

and then dive into the major categories.

2:56

Um, how certain skills surrounding your use of pacs, um,

3:01

around the use of templates

3:03

and reporting style, uh, sort of strategies,

3:05

and then other things beyond the workstation

3:07

that can be helpful, uh, you know, in service

3:11

of improving, uh, efficiency.

3:13

Okay? So, you know, big picture,

3:17

like why does it matter to, uh, develop these skills?

3:21

And this is not just merely to grind out more cases

3:25

or, you know, um, you know, finish the work sooner or, or,

3:29

or though that is an important part of this.

3:31

It's in part because if we can modulate

3:34

how much time we're spending on more simple cases

3:37

or just doing the kind of necessary repetitive parts of

3:41

what we do on a day-to-day basis as a radiologist,

3:43

we have time, more time for complex cases.

3:45

You can look more deeply into the patient's, uh, chart and

3:49

or, you know, cross correlate across more priors,

3:53

differing modalities.

3:54

And, and when cases really require you to slow down

3:57

and kind of think more deeply, you have time for that.

4:00

And there's not stress

4:01

to keep moving when you really need to dedicate more time.

4:03

And that's like a critical part as well.

4:05

And it should be, you know, it's well recognized

4:08

that imaging demands are continuing

4:10

to grow this stress on radiologists to, you know, keep up

4:14

with the list and to, you know,

4:16

take on more and more volume.

4:18

Um, is that, that is experienced

4:20

by radiologists all across radiologists all across the

4:22

world, and there are downstream impacts on

4:24

the way care is provided, right?

4:25

So this is, you know, we at least in, in the states are,

4:28

have faced crises in ed boarding and hospital boarding.

4:32

Um, and we, um, uh, in radiology, like our reports

4:37

and our consultation are often a rate limiting step in

4:40

patient disposition or care.

4:41

So our ability

4:42

to provide those consultations really efficiently and, and,

4:45

and in a manner that is timely

4:46

and a huge impact on patients, the anxiety of patients

4:51

and families, um,

4:52

and then also our relationships inter, uh,

4:54

interprofessionally with our, you know, referring

4:56

and consulting, um, clinical staff, um,

5:00

obviously important scenarios, stroke care

5:02

and other hyperacute scenarios where like being able

5:05

to literally consult sooner

5:07

or provide, you know, guidance

5:10

to clinical teams sooner impacts patient outcomes,

5:12

like immediately, indirectly.

5:13

And of course, for those in academics

5:16

or those who juggle different things,

5:17

or those of us who simply want good work life balance

5:19

and to attend other things, being able

5:21

to get the work done in a timely manner, um,

5:24

just facilitates all that.

5:26

Um, and I've, I've noticed quite, uh, importantly for those

5:29

who are still in training, that those

5:31

who in parallel develop the skills to have some, you know,

5:35

go through cases a little faster and, and see more.

5:38

They learn at a faster clip, um, and it,

5:40

and it makes them, you know, better radiologists.

5:43

I, I think, uh, and we do see that trend here is, um, a kind

5:48

of un unlabeled axises, uh, plot of real volume data, um,

5:52

taken from my institution of fellows

5:55

and how many cases they read, um, in a a given timeframe.

5:57

I believe this is in a, in a, in a quarter,

5:59

so three months in, in, in a span of differing people.

6:02

And it is basically my experience, um,

6:06

this is actually several years ago, so this is, uh, um,

6:09

but, um, where in any given group, you know, the, the, the,

6:13

the, the span or, or range in efficiency

6:16

or ability to handle cases may, may differ

6:19

by a factor of two or more.

6:20

And so, you know, this is,

6:22

we're just talking about being able

6:24

to move the needle a little bit for yourself, um,

6:26

and gain, you know, 5%, 10% gains

6:29

and, uh, in terms of efficiency, right?

6:32

Um, and, and what does this mean in terms

6:33

of like actual dollars or, or, or, or,

6:36

or hours or time, right?

6:38

For an individual radiologist, right?

6:40

So if we, if we just do some estimated numbers, right?

6:43

Currently in the United States, you know,

6:46

average radiologist salaries are approaching

6:49

or around, let's say around a half million

6:51

for 30 year career, you're looking at about 15 million.

6:53

There's a certain number of, you know,

6:55

let's call it somewhere between a half

6:57

or to what, like, uh, you know, 50 to a hundred

7:00

thousand hour hours you'll spend in your career.

7:02

And then if you just estimate the value of being able to get

7:06

through the work, you know, a certain amount faster in terms

7:09

of the value, in terms of dollars

7:11

or time, even a single percentage gain is worth, you know,

7:15

hundreds of thousands of dollars,

7:17

or, you know, up to a thousand dollars of, you know,

7:20

I'm sorry, a thousand hours of life time

7:22

that you can recoup just

7:24

by 1% improvement in efficiency, right?

7:26

Um, in terms of time that is just hidden

7:29

and dispersed a a among the hours, uh, of work.

7:32

Um, but for most people in early career, you, you know,

7:36

I'm saying that there's like at least a two x difference in

7:38

people's ability to move through cases.

7:41

Um, you know, even, even a 10% gain is worth millions

7:44

of dollars and hundreds, you know, you know,

7:46

I'm sorry, thousands of hours of life.

7:48

So this is a big deal for radiologists and,

7:51

and, uh, personally, professionally,

7:53

and in many ways, okay, so this is just, I just wanna,

7:56

you know, putting that emphasis out there can,

7:58

can just show you, um,

7:59

if we're not spending a significant amount of time trying

8:02

to build these skills, um, we're leaving a lot of

8:05

that on the table, okay?

8:06

Um, and, and that's something we want to, uh,

8:09

we wanna be thoughtful about as we approach the early stages

8:11

of our career and even, even even later, um, uh,

8:14

in lifelong learning.

8:16

Okay? So I will say that a lot of what I,

8:18

I talk about in terms of strategies are very context

8:20

dependent for trainees, you're

8:22

first audience is you're attending.

8:25

Um, you wanna make sure that you, you know,

8:28

whatever you do is, is, you know, appropriate to,

8:30

what is the expectation of those, uh,

8:32

who are reviewing your, your reports,

8:34

and then your referring services.

8:35

Everything, you know, it's gonna

8:36

depend on what do your clinicians want?

8:37

What are they looking for? What is the local

8:39

practice standard, right?

8:41

Um, and I'm gonna be talking about, you know, approaches

8:44

that are just, they're not necessarily the right way.

8:46

They're just one way, you know, and,

8:47

and I'm hoping not necessarily to tell people what they have

8:50

to do or should do, but providing, um, a menu almost

8:54

of potential strategies of, of, uh, things

8:57

to think about food for thought,

8:58

and how to hone your own skillset.

9:01

Um, and a lot of these things are not that complex.

9:03

Um, they're, they're just a suite of things that as,

9:06

as we kind of smooth out the process

9:07

and make all the steps of our work a little bit, uh,

9:10

a little bit cleaner, um,

9:12

that in totality they can help us come together and,

9:16

and then your overall efficiency is, is will be improved.

9:19

Okay? And so, and I I do wanna emphasize, you know,

9:21

and while, while I said this in, in a small way

9:23

before, being efficient is not necessarily just going

9:26

faster, it's not doing the same things we are always doing,

9:29

you're, we're usually doing,

9:30

but just trying to, with more stress

9:31

and trying to go them faster or rushing

9:33

or kind of corners, it's about reducing unnecessary emotion

9:37

or finding, um, you know, a more, uh,

9:42

a less effortful way to get from point A to point B

9:44

that still accomplishes the key things

9:46

and providing the highest level of care with the, um, with,

9:50

with a means that where the, where the time

9:52

and effort, uh, involved is, is, is dialed

9:55

to the appropriate amount for each, uh, case.

9:57

Okay? So I just wanna make sure that we en emphasize that.

10:00

Um, so, uh, the major, you know, one of the major, uh,

10:05

let's just say buckets of, of, of how we can do this is,

10:09

and I would encourage, um, uh, uh, uh, people who've moved

10:13

to new systems to, to really emphasize the development

10:15

of practical skills and how, how you interact with the, uh,

10:20

pacs and, and, and, and, and, and,

10:21

and this basically comes down to minimizing the number

10:25

of actions you have to use for each, um,

10:30

to access each tool or to perform each action, okay?

10:33

Um, as well as to leverage some advanced tools, excuse me.

10:38

So for example, I try to teach newer trainees, um, and,

10:42

and though this is a, a thing that I see in, you know,

10:45

radiologists have been practicing for many years, is

10:48

that anytime you're trying to access a tool, arrow key,

10:50

scrolling, windowing

10:51

and leveling, um, I, I sometimes see people

10:55

clicking on the screen to, you know,

10:57

and so this is example images from our, uh, packs is, um,

11:02

you know, clicking on actual tools on the toolbar are right

11:05

clicking to switch between window and leveling and scrolling

11:08

and panning, or to access to access.

11:10

It's much better, um, to be able

11:12

to access every single tool with a single action.

11:14

You know, uh, we have, uh, in our packs,

11:16

which have no relationship, uh, you know, uh,

11:18

professional relationship with, but it's Vistage.

11:21

I mean, it's not quite good, but you can assign any tool

11:25

to a hot key on the keyboard.

11:26

Um, and so what I tend to advise people to do is

11:31

to learn every single hot key, um, as soon as possible,

11:35

and to access every tool, um, by bringing up their,

11:39

their kind of like the key and reassigning.

11:42

Um, and it should be, you know,

11:44

as the, it should be muscle memory.

11:45

So I basically use every key, you know,

11:48

I personally use like every key on the keyboard.

11:50

I know what every single one does.

11:51

Um, and I never, I, when I'm working,

11:54

I never do the right click,

11:55

or let's just say rarely, rarely do the right click thing

11:58

and bring up a toolbar or,

11:59

or have to do anything where I have

12:00

to search on the screen to access the tool.

12:02

So that is like a very basic thing.

12:04

And anytime you move institutions,

12:06

investing in this core knowledge is really critical.

12:09

Um, and I would even say just focusing, you know,

12:13

what we do, it's thought of as cerebral and cognitive,

12:16

but there is a, you know, um, a, a part of it

12:19

that is muscle memory, that is, you know,

12:22

um, that is physical.

12:23

There is, uh, I mean, I've, I've, I've had a, we had a, one

12:27

of our great fellows, um, in, in neuro, uh, uh,

12:30

talk about there is an athletic component.

12:31

There's a thing where you, where there's almost like this

12:33

mechanical aspect where you have to, where if you develop

12:36

that and you get really good at that,

12:38

that is gonna serve you very well.

12:39

At our institution, I've also developed basically like

12:42

macros and dev and, and,

12:44

and guidance documents for people who just joined.

12:46

So all of our new residents and, and, and,

12:48

and, um, you know, new faculty are interested, provide them

12:52

with basically a cheat sheet for all, all

12:54

of the most important tools.

12:55

And so this is something at any institution,

12:58

if you are thinking about, like, you know, we, we,

13:00

we teach each each other how to, um, you know, do some

13:04

of the things in radiology, how to, you know,

13:06

other kind of systems based learning.

13:07

But this is a critical thing

13:08

that if you create some guidance documents, um, uh,

13:12

it's easily reproducible in the marginal effort

13:14

to onboard people, um,

13:15

and to refresh oneself is, is, is becomes less.

13:18

So I wanna show some kind of interesting, I would say, um,

13:22

let's see, um, tools that are available, um,

13:27

in our packs and, and talk about their utility.

13:29

So one of the key things that I do, um,

13:32

for basically all cross-sectional imaging is I use the NPR

13:36

viewer, and there are some, uh,

13:38

important advantages in this, in that there you can,

13:42

you know, you can correct the accesses.

13:44

And the nice, one of the nice things too is to be able to,

13:47

um, so you can see here I've got, uh, oops,

13:50

lemme just go back here.

13:51

Um, I've got thin sec thin section images,

13:54

and the nice thing is that in our NPR, we can create medium,

13:58

um, thickness images, um,

14:02

that small scroll smoothly, rather in a book-ended fashion.

14:06

So I'm gonna show you first how, you know,

14:09

some less efficient waste that we are able

14:11

to change the slice thickness

14:12

and toggle between MIP min and average.

14:15

And then I'll, and then I'm gonna go through, um,

14:17

and I've got, I had to like prerecord this video

14:19

to avoid accidentally showing

14:20

PHI when I like go through cases.

14:22

But, um, as you can see here, there are hotkeys between,

14:26

you know, using the mouse

14:27

and the keyboard, um,

14:29

to basically change the slice thickness dynamically

14:31

so you don't have to rely on the preexisting,

14:34

um, reconstructions, right?

14:35

And then to toggle, so you basically have access

14:38

to real time, um, you know, uh,

14:42

mins MIPS average intensity.

14:44

And being able to leverage that is incredibly powerful.

14:47

Um, basically that is a skill that has allowed me

14:49

to be much, much faster than people

14:51

who do not have to skill.

14:53

Um, what I'm now showing is, uh,

14:55

something called a tool called three overlay or, um,

14:58

or co-registration where I've taken a current study

15:01

and a prior study, and they're overlaid three dimensionally

15:03

within the NPR viewer.

15:05

Okay? This may not be available in all, uh, pacs,

15:08

but it's an incredibly powerful tool,

15:11

and I basically use it every single study.

15:12

Um, so what I'm now showing is

15:15

that they have been coregistered,

15:16

and there's this little toggle thing

15:17

where on the left you pull the toggle

15:19

and you see the current, and you

15:20

pull it to the right, it's the prior.

15:21

And you can notice, and I'm gonna highlight here

15:23

with some arrows, um, that there are,

15:25

that this is gonna allow you to detect subtle outer

15:28

here in the case new, uh, subdural collections,

15:31

which produced some local mass effect.

15:32

And this ability to compare things in a very intuitive

15:38

and visually appealing sort of way, um,

15:41

makes a huge difference in your ability

15:43

to very quickly get the sense

15:44

of the overall changes in cases

15:46

and then to tuck subtle abnormality.

15:48

And this tool, in addition, has

15:50

provided amazing marginal gains.

15:52

Um, so, so if your PACS has this, I would advise

15:55

that you learn how to do this

15:56

and leverage it to its maximal extent.

15:58

Um, there is a similar tool in our PACS that, that I want

16:01

to kind of highlight.

16:03

And again, um, it's availability

16:05

or applicability to other settings is, uh, you know,

16:07

it's gonna be variable, but similarly you can

16:10

3D overlay a current and prior.

16:11

So here, I've, I've overlayed a current

16:13

and a prior, um, MRI, uh,

16:16

in a patient has multiple sclerosis.

16:18

And I've highlighted here the, well, let me, let me show you

16:21

how subtle the difference is in the current

16:23

and the prior, um, in that you can almost,

16:26

you can barely make out, uh, a change where there's,

16:29

there's, as I scroll the bar left

16:31

and right, there's a new lesion, uh, in the, you know, uh,

16:34

parietal white matter, but then if you create subtraction

16:37

images, which in some packs you can do dynamically,

16:39

so you don't have to have the technologists do it, um,

16:43

that allows you to,

16:44

to pick out subtle lesions a lot quicker.

16:47

And there is this obvious, there's this balance

16:50

of this tension between, um, uh,

16:54

uh, let's see.

16:55

Um, I've got some questions. And let's see.

16:58

And I, I can't answer this question as we go.

17:01

Um, in regards to, so we have thins on

17:06

every single imaging study that comes through, um,

17:08

different institutions are gonna have this, uh, uh,

17:10

different availability.

17:12

And I recognize that at some institutions,

17:13

you don't get thins across the whole body,

17:16

like abdomen, pelvis.

17:17

It's pretty common in some institutions

17:18

to not have thin section images.

17:21

Um, but, uh, at our institution,

17:24

we have thins for everything.

17:26

Um, and it is something if you are a part of, you know,

17:29

your practice administration, you have a their ear,

17:31

and this is something that is important,

17:33

uh, you might think about that.

17:35

I, there is this feeling, I think, among radiologists

17:38

who maybe are further in their tr, you know,

17:41

who are further in their career, that if you add more images

17:43

to the, to the, to the packs

17:45

or to the study jacket, that you create more work by

17:49

making more things to look at.

17:51

Um, but, uh, there is, um,

17:55

but, um, the, uh, you know,

17:59

but in fact, having those thin images

18:00

to reconstruct them actually can save a lot of work.

18:04

Um, so, uh, that's kind of a, a critical thing.

18:07

And I, I'll come back to additional questions at the end,

18:09

but I thought that was relevant, right as we go.

18:11

So, so these are skills that,

18:13

or tools that may be available in some, uh, packs.

18:16

And, um, so I just wanted to highlight those.

18:18

If you do have availability,

18:19

and then kind of, um, just as a broader, um,

18:23

bigger picture idea, you know, emphasize the importance

18:27

of developing those tools early,

18:28

leveraging them as much as possible.

18:30

Okay. I will say there are some other kind

18:32

of critical thing, you know, these are small advances in

18:35

terms of, you know, if there's a, for MRI studies

18:38

or for things where there's a lot of imaging sequences, um,

18:41

you know, instead of hanging, you know,

18:44

hanging every single sequence

18:46

and then tapping through, in some cases, it's helpful

18:49

to use the all images stack, reducing the number of clicks

18:51

or actions that are required.

18:53

Um, uh, I will often, you know,

18:57

it depends on practice setting, but I will encourage people

18:59

to use the study annotation,

19:01

like annotate images rather than report dictate, um,

19:05

like image numbers and, you know,

19:07

if it's appropriate for the clinical setting.

19:09

Um, in many cases, it's not, you know, it's not, uh,

19:13

in some cases clinicians will want image numbers,

19:15

but in our pacs,

19:17

and I also, I've actually found that

19:18

as someone reading follow up studies,

19:20

and then clinicians like oftentimes prefer annotations

19:24

with impacts rather than image numbers.

19:26

'cause then you have to like, open up a sequence.

19:27

You have to check, you have to, you have to look at the,

19:30

you know, the reported image numbers,

19:31

scroll until you get there.

19:32

And then, you know, you may not even have an arrow on it,

19:35

like it's just better to throw an arrow or a circle

19:37

or something that that's just like a lot faster.

19:40

Um, we do have some tools,

19:41

and there's been some, you know, some evidence

19:43

that AI-based, you know, help

19:45

with detection can improve

19:46

our ability to move through these cases.

19:48

And frankly, I, I, I continue to develop these skills, um,

19:52

as an attending radiologist.

19:54

I, you know, the muscle memory, the, the fluency with,

19:57

with my system

19:58

and the software, it's, it's a continual stage, um,

20:01

process development, uh, or, and improvement.

20:04

It's something I would, I would encourage everybody

20:07

to really invest in and to continue thinking about,

20:09

and always look for new tools and ways to, um, develop

20:13

and disseminate this sort of understanding.

20:15

Um, I will say that a fluency with using, um,

20:19

or rather a, um, a, uh, you know, rather,

20:24

uh, familiarity with using the, the tools of PAX is,

20:29

is really, um, important.

20:31

I will say that that makes up my estimate is like something

20:34

like 30% of the variation or, or something.

20:37

And, and, and in people's ability to move

20:39

through cases in an efficient manner, I would say

20:41

that in parts, the reporting of the variation in

20:45

how people use templates, macros, they,

20:48

how they free dictate, um,

20:50

is probably the largest very accounts

20:53

for the largest variation in people's efficiency.

20:55

Um, and so I'm gonna go through a couple, uh,

21:00

examples comparing, um, reports

21:02

and, um, some fundamental principles

21:04

and strategies that can be helpful for making sure

21:06

that you're, you're as efficient as you, as you can be

21:09

for your, um, for your, the clinical setting

21:11

that you're, you're faced with.

21:13

So early in training, a lot of train, you know,

21:16

people develop a, uh, an approach to

21:20

practicing radiology where they go through the image

21:22

and they just report everything they see and, and, and it,

21:26

and they, they just, they describe everything

21:28

with some variable amount of detail,

21:30

and at the end, they, they go back

21:31

and they think to themselves, okay, so

21:33

how do I put these together to, for an impression?

21:35

And this is a, you know, a really good way to start.

21:37

But I would say as people become more experienced,

21:39

or as you get further, it's very helpful

21:43

to take a very holistic, um, view of the work we're doing.

21:47

We're there to make a difference, uh,

21:49

in patient management, right?

21:50

We're there to, uh, provide meaningful, uh, consultation.

21:54

So it's, it's, it's important, um,

21:56

and it can improve one's efficiency to think to yourself,

21:58

okay, for this patient, given their care up to this point,

22:02

how is this imaging study

22:04

or its results gonna impact their management?

22:06

Right? And then you kind of, you can build

22:09

how much detail you provide for certain things around

22:13

that idea, okay?

22:14

So, you know, what is the impression, you know, the most,

22:17

the complete impression that helps motivate,

22:20

helps guide the clinicians

22:21

to provide the appropriate care for this patient?

22:24

And then how do we go through

22:26

and provide the findings in such a way

22:28

that we're providing the pertinent positives

22:30

and negatives without descr describing, with excessive,

22:32

detailed things that are not important

22:34

to the patient's management, right?

22:35

So, and then how do we develop the skills to the skills

22:39

and the tools to accomplish that, you know, macros

22:41

and templates and, and, and certain reporting styles.

22:44

So for example, like how does this play out in a, in a,

22:47

in a meaningful way, is that it can help you understand,

22:51

it can help, uh, people understand that you don't need

22:53

to go into great detail about things that are, um, in,

22:58

you know, that are, that don't impact management,

23:00

that are stable, that are normal variants

23:03

that have no relevance to the clinical setting or have,

23:06

or things that have been previously described.

23:07

You don't have to tell the clinicians things they already

23:09

know for, you know, describing the, the,

23:11

in some circumstances, let's say, um, of, of

23:15

every different way in which post-surgical change,

23:17

for example, manifests if it is already pair

23:20

or has already been described, right?

23:21

So, um, I will say that, you know,

23:23

the basic idea is if it doesn't change management,

23:25

you wanna spend less wording

23:27

and remove wording that ha that has less meaning, you know?

23:32

And then you can, you can consider, um, you know,

23:36

in some circumstances you're gonna use complete sentences.

23:38

Um, in some cases, you know,

23:40

and I practice emergency radiology,

23:42

so our referring clinicians, they prefer brevity.

23:45

And so a lot of times it's gonna be very helpful to, um,

23:49

to leverage the concept of using like Nora more brief.

23:51

So here's an example of two reports

23:53

that say basically the same thing, right?

23:56

You can notice here this,

23:57

where you're using complete sentences, there is prominence,

23:59

da, da, da, there are Apache, bilateral aerospace opacities.

24:02

There, there's bunting where, you know,

24:04

and then the impression, um, repeats a lot of stuff

24:09

and then, um, and then provides a differential.

24:11

So here, as you can see in a, in a much briefer example,

24:15

that, that includes all the words

24:18

that have the most meaning, you know,

24:19

and motivate motivates the same.

24:21

There, you know, we're leveraging noun phrases.

24:24

We're, we're basically complying

24:25

that anything listed here is a finding.

24:27

And we're, you know, we're using less

24:29

of these declarative words.

24:31

You know, there is, again, noted that sort of stuff.

24:33

Here's another example, um, for brain imaging.

24:36

Um, this is a lot read so that you can skim it.

24:38

So he, on, on this, this, um, longer example

24:42

that is just describing everything we see.

24:45

We talk about the skin staples, we talk about, you know, all

24:49

of this post-surgical change, which is,

24:50

which just o often known, you know,

24:53

you could just call it if, if you've seen a hundred

24:55

of these, and they're always this, and it's expected, uh,

24:57

in some cases, the surgeons don't care

24:59

that they're skin staples.

25:01

They know that there are skin staples. You know what I mean?

25:02

Uh, so you don't have to talk about that.

25:03

Or in many cases, you don't.

25:04

Let's just say, um, so you could just say

25:06

that there are expected post-surgical changes,

25:08

and then you have to, you can just emphasize the importance

25:10

they have mood or surgical drain.

25:12

Um, you know, you can, you can note the,

25:15

the difference in the ex the excessive wording here on

25:19

things, um, that, uh, maybe don't matter that much, right?

25:23

And so we can basically take the key bits there

25:26

and just emphasize the key bits,

25:28

and you can notice how much more readable this is.

25:30

You know, and you can see here that, you know,

25:32

we've described, and this is, you know, a lot

25:34

of this is actually taken from my institution examples for

25:36

how our tra trainees and other people report where I think

25:40

that you can get lost in here.

25:41

You just want to, you wanna, for the clinician,

25:43

it's sometimes it's helpful to just know

25:44

that either things are stable

25:46

or there's nothing unexpected or acute, right?

25:47

So, um, in a lot of circumstances,

25:49

and that is the case, you want to, um, emphasize that point.

25:53

Um, I will say there is a fine balance here, right?

25:57

So as the cases become more complex,

25:59

you wanna spend more time, right?

26:00

You wanna spend, you wanna, you know, maybe

26:05

think about moving through cases where it's stable,

26:08

negative, and you know, or like,

26:09

it's more, it's more simple.

26:11

You wanna spend, try and spend less time,

26:13

but then it's maybe not entirely,

26:15

it's not necessarily the best practice to always feel like,

26:17

oh, I'm gonna move through cases fast all the time.

26:19

That's, that's not, uh, always gonna be the best thing

26:22

for the patient, the best thing for the care of that.

26:25

In that instance, as cases get more complex or,

26:27

or there are differentials, you're gonna walk through,

26:30

or there are scenarios that you

26:31

wanna be more thoughtful about.

26:32

Like, it's important to have this range of

26:36

how we engage in cases, right?

26:38

Being really, you know, recognizing that we gotta move

26:42

through some with a little, little bit more quickness.

26:44

And then some will be like, Hey, let's,

26:46

let's slow down, let's think.

26:47

So, you know, spending too much time on every single case,

26:50

you know, is probably not gonna

26:51

be helpful for your efficiency.

26:52

But then being able to pump the brakes is important too.

26:55

So here's a, a example that is inspired by a real life

26:57

where, you know, we've got a patient and a chest x-ray,

27:01

and this is really basic.

27:02

We're just going to things that apply to,

27:04

like most radiologists, right?

27:05

Um, you know, where there are, this patient has underlying,

27:09

you know, COPD, they've got, you know, aids

27:11

and they're, they're, you know, they're,

27:13

maybe they're immunocompromised, you know,

27:14

they have all sorts of risk factors.

27:16

And, um, a radiologist describes, you know,

27:19

worsening airspace, opacities, um,

27:22

and I'm not gonna have the images here,

27:24

but you can imagine one area looks mass, like,

27:26

and this has gotten much worse,

27:27

and they've just described, they've repeated the,

27:30

the imaging findings and the impression,

27:31

but we really want to provide, you know,

27:33

obviously we wanna be helpful, we wanna provide, you know,

27:37

used terms that are useful to clinicians in our impression.

27:40

So in a different setting, you may want to think

27:42

to yourself, Hey, these patients are, they're at risk,

27:45

not just for the u routine infections,

27:47

but there could be infectious etiologies.

27:49

And then patients who have HIV

27:51

and aids, they are also at risk, higher risk

27:53

for certain malignant, uh, uh, processes, neoplastic things.

27:57

And if it looks like a mass, then it's useful to maybe,

28:01

you know, recommend for their evaluation.

28:03

You know, so sometimes it's, you know,

28:05

and similar, like a nice other example

28:07

that I frequently encounter is

28:09

you have spine metastatic disease, right?

28:11

You could just say similar or worsening,

28:13

but like sometimes if it breaks

28:14

through the po posterior cortex, you know, um,

28:17

you may wanna recommend an MRI,

28:18

and you're seeing an on ct, you know, you know, on,

28:21

on a workup in that manner you may want.

28:23

And, and there might be some involvement

28:24

of the cord, the thecal sac.

28:25

You wanna slow down think, Hey,

28:27

what change in management may occur?

28:28

You may maybe we're recommending MR mri.

28:30

So we we're trying to, um, titrate the, the, the,

28:34

the degree of detail and thoughtfulness to, to the exam.

28:37

And this, this concept of modulating, uh,

28:40

the detail is, is very important.

28:42

And this is something that you develop

28:44

as you as through training.

28:45

And then as we talk

28:46

to our clinicians throughout our professional lives

28:48

to understand what's important to them, who's keeping up

28:50

with literature, and that will help inform being more

28:53

informed about what matters is gonna make us, uh,

28:55

more efficient and more useful.

28:56

And so that, I think just to, um, uh, touch on those points.

29:00

So, you know, I'll go through a couple more specific, um,

29:03

strategies in terms of for free dictation.

29:06

Um, uh, let's say, you know, I, I've already mentioned

29:11

that we can minimize the use of words.

29:13

Like there are, if you're, if you can kind of get away with,

29:15

um, just, you know, describing, you know,

29:18

stable patterning attacks, rhythm, there are, right?

29:21

Um, instead of saying we are again, seen, are observed,

29:25

you know, um, sometimes you can just state the finding,

29:28

you can just state the thing, right?

29:30

So minimizing perceptive terms, um, especially things

29:33

that don't matter in terms of, um, stability.

29:37

Um, you know, it doesn't really matter often if hepatic, uh,

29:41

cysts or renal cysts are stable.

29:43

Uh, if, you know, you don't have to give a lot

29:45

of details if it's already implied

29:46

or if it's, you know, you just say stable, you know?

29:49

Um, and then, you know, I prefer stable

29:51

or similar to no significant change compared to dah, dah da,

29:54

this exam, you know, accounting for different techniques,

29:56

you could say a a lot of

29:58

that can built be built into more

29:59

efficient language, you know?

30:01

Uh, exactly.

30:02

And, you know, in some cases describing in a lot

30:06

of detailed things that are not actionable, you know,

30:08

let's just say talking a lot about degenerative change in a,

30:11

in a per in, in, in a way in that's mild,

30:13

that's not gonna be acted on, you know, in an acute setting

30:16

or a patient that has metastatic cancer

30:18

and they're not gonna act on it or they're not a candidate.

30:20

Um, only if, you know, we can think about doing that if it,

30:23

um, explains the patient's symptoms.

30:25

But if things that are, you know,

30:27

of less contributory nature,

30:28

we wanna think about using nice default,

30:30

permanent positive and negative images.

30:32

Um, and because it's also useful to recognize

30:34

that sometimes, you know,

30:37

you don't have to be that specific.

30:38

Sometimes, you know, like I was saying,

30:39

say post-surgical changes, you could say, you know, uh,

30:42

eclipse are here, and you don't have to, you don't,

30:44

you know, sometimes I have trainees that I work with,

30:46

they get almost like they, they, they assume that

30:48

that eclipse are, you know, right, right upper quadrant.

30:52

They, upper, upper abdomen are from a cystectomy,

30:53

but there are, you know, adrenalectomy

30:56

and partial hyper there.

30:57

Sometimes there are a whole bunch of like, rare things.

30:59

So you, you, it to avoid having to actually like,

31:03

do further digging on things that aren't relevant

31:06

to the patient at that time,

31:08

and where, where you're gonna help, you know,

31:10

that aren't gonna allow, help you help the, the clinician

31:12

and therefore help the patient.

31:14

Um, you can, you can titrate the level of detail

31:17

that you're providing, and that's a very useful thing.

31:20

Um, I'm a big fan, um,

31:22

or I, I particularly try to advise people, um, to

31:28

minimize their use of the word demonstrated.

31:29

Um, 'cause it's kind of vague. You don't want to say,

31:32

you know, um, you know,

31:34

an intracranial lesion is re demonstrated this,

31:36

this just means you see it again, you could,

31:37

you you wanna say, is it stable?

31:39

Is it larger? Is it smaller?

31:41

Um, so, you know,

31:44

and so preferably you'd say something like, um, you know,

31:47

the intracranial ma, you know,

31:48

stable enhancing intracranial mass, you know,

31:52

measuring three centimeters, you know,

31:53

so describing description and the finding.

31:56

And then if you have to use sentences, you could say,

31:58

you know, enhancing, uh, you know, al lobe, uh,

32:02

lesion measures, three

32:03

centimeters, something like that, right?

32:05

So, um, especially if, you know, I,

32:07

I definitely have trainees who say like, re demonstrated

32:10

dah, dah, dah, dah, dah, the lesion, you know,

32:13

unchanged from prior studies.

32:14

So there's like 10 extra words in there.

32:16

And, and so being able to kind of hone that down

32:19

and just, you know, look, look for ways to, to, to make, um,

32:23

uh, uh, to, to kind of come up with a format

32:28

or style that touches on the most important things, again,

32:31

just highlighting that sort of sim uh, similar format,

32:33

it can be very advantageous for those working in high volume

32:37

or com, you know, complex settings.

32:38

And then, and then, then, and then,

32:39

and then again, you know, pausing

32:41

to go into much deeper detail, um, when,

32:43

when it's necessary, and trying to touch on the things

32:45

that change management and that really matter.

32:47

And so here's a collection of potential useful strategies

32:50

that, um, you know, some of which I touched on, um,

32:54

that these are taken from, uh, uh, uh, one

32:58

of my textbooks, uh, as well.

33:00

Um, so you can take a look at that or screenshot it

33:02

and, um, yes.

33:04

Okay, very good.

33:05

Um, so I wanna talk a little bit about some principles

33:07

around designing great macros, um, or templates.

33:12

Um, there are a lot of ways to do this,

33:16

and a lot of times people, um, it can be easy to go

33:21

with whatever defaults at in your institution.

33:22

Um, but it's ideal, uh,

33:24

or, uh, to think about what is most advantageous,

33:28

um, in any given setting.

33:30

And so there are certain things that, you know,

33:32

and again, these are applicable in certain circumstances,

33:34

applicable, not, but ideally, we, you know,

33:37

you want default templates that are easy

33:39

to read and navigate, right?

33:41

Like, I particularly like a bulleted

33:43

or a structure format where it's easy to like, visually see

33:45

where you want to click or navigate, um, uh, to, uh,

33:51

report a certain finding, you know,

33:53

so people use like a findings mode

33:54

or like an automated thing that puts them in.

33:56

I have systems allowed to do that, right?

33:57

I tend to like to avoid having listing out many,

34:01

many abnormalities or atopic sites in a single line if we're

34:04

using that structure format.

34:05

Because then if you add an abnormality,

34:08

then you're obligated to go back

34:09

and change the default text.

34:12

And I working with trainees,

34:13

oftentimes trainees forget to change the default text.

34:16

They just leave parts of the template

34:17

and that contradict their additions, right?

34:19

Um, I love pick list, uh,

34:21

and it's not gonna be right for everybody,

34:22

but I, you know, there's error in voice dictation.

34:26

Um, and especially if there's in, in, you know, um, problems

34:29

with internet, if you're working remotely, if you know, if,

34:33

you know, if you're working, there's background noise,

34:35

it can kind of screw that stuff up.

34:36

So minimizing the chance for error

34:38

and the need for proofreading

34:39

or fixing dictation errors is really important.

34:42

I, I really think it's important to have certain, you know,

34:45

sometimes because of maybe a pedantic

34:48

or a, you know, a certain, uh, perfectionistic

34:52

or whatever perspective, if,

34:54

let's just say you're using unremarkable

34:57

for the vessels on an addin pelvis,

34:59

but like, there's atherosclerotic disease

35:00

and then it's not like technically unremarkable.

35:02

It's not like really tech unremarkable.

35:03

But then if you, you might feel compelled to change,

35:06

unremarkable to talk about atherosclerotic disease,

35:08

even though it's like, not contributory.

35:09

'cause everybody patient, it's already known they have like,

35:11

coronary artery disease and, you know,

35:12

talking about a little bit atherosclerosis peripherally,

35:15

like it's not gonna make a big difference.

35:17

Um, so like having good default wording

35:20

and then having as much automation built in to, um, the, um,

35:26

um, what is it, um, into the templates as much

35:30

as possible is, is very helpful.

35:32

Um, so let me, yeah.

35:35

So here's a couple examples of default languages, uh,

35:39

that is helpful to avoid prompting people to, you know,

35:43

make changes that may maybe don't matter that much.

35:45

So something like, um, you know,

35:48

like I had mentioned, the vessels you, right?

35:49

So if you're in the abdomen, you could say there's no an,

35:51

you know, no, give that pertinent negative to something

35:53

that's important, then that's just a prompt to remind us

35:55

to go back and change it if it's important, right?

35:57

You know, similar, like everyone's got DGen n right?

35:59

So it's like if, are they really unremarkable?

36:01

If they have degenerative change, you know,

36:02

we can give the pertinent positive negatives of, you know,

36:05

acute findings or fractures in center trauma,

36:07

or, you know, together with aggressive OSCE lesions

36:09

or suspicious OSCE lesions

36:10

or something like that, uh, to word for other processes,

36:13

you know, malignant things, right?

36:14

And then, uh, you know, for example, you know,

36:16

if you're partially imaging certain structures,

36:17

you wanna say no evidence of

36:18

or nothing seen, da, da da as part of the default.

36:21

Um, and that give, that builds in a caveat

36:23

with marginal additional effort, um, which is nice.

36:26

Um, okay. I think that that's all I want to say here.

36:30

You know, other evidence, you know, I'm sorry,

36:32

the other examples of phrases that can be helpful

36:36

to build into the default, you know, um,

36:38

and I, I said that terms of perception are, can be, um,

36:41

disadvantageous used in free dictation,

36:43

but building them into the template can be helpful.

36:47

If you need a, you know, caveats like I, I often like

36:50

to say, you know, the perinasal sinuses

36:52

and the orbits are not often totally included in the field

36:54

of view for head CT imaging.

36:56

So it might not be technically correct.

36:58

See, the orbits are normal,

37:00

or there's nothing in the orbits if

37:02

you don't see the whole thing, right?

37:03

So this is, this is a little bit getting into the weeds,

37:06

but just having, you know, any,

37:07

but oftentimes, you know, if in a default template,

37:10

also having default ordering that says, um, no evidence of,

37:14

and that it's helpful if like there's like motion or streak

37:17

or some other way that the thing is the study's degraded.

37:19

'cause then that still applies, right?

37:22

Um, I'm gonna go through, I'm gonna show some examples of

37:26

I this is, this is a, you know, a, a chest x, you know,

37:30

a chest radiograph, uh, template that I use,

37:33

and everyone can do things differently.

37:35

You know, a lot of people just free dictate this.

37:37

But as you can see, for me, I basically,

37:39

my default has pick lists for every single line,

37:43

different degrees of edema, vascular congestion, um,

37:47

basically every single thing that I would use to,

37:50

to replace any given line is available as a tick list.

37:54

And so I still free dictate.

37:55

Sometimes I'll delete the whole report

37:57

and I'll just report freeform a couple lines.

38:00

Sometimes I'll just report over a specific lines.

38:02

I, but, um, I'm showing you similar for MSK radiographs,

38:07

like basically every single thing

38:09

that I would say commonly I have is a pick list.

38:12

And so that is a strategy that can be

38:13

helpful if you like this.

38:15

And I, I, a lot of reports, I say,

38:17

I actually speak to the mic.

38:19

Like, I, I basically don't say anything to the mic.

38:22

I just like click or I say pick one, pick two.

38:24

And I just like, and it's very fast.

38:26

Um, and it's very helpful and reproducible.

38:28

And there are few dictation errors.

38:29

I'm now showing a similar concept, right?

38:31

And you can notice here, like there is one abnormal,

38:34

you know, potential abnormality or,

38:35

or anatomic area per line.

38:37

And again, you know, some people will have like the,

38:39

the name of the anatomy and the

38:40

colon, you know, unremarkable.

38:41

That's good too. Um,

38:43

everyone will do it a little differently,

38:44

but this is compatible with my institutional, uh, style

38:47

or what is expect, you know, seen at my institution.

38:49

You can see that every single line, you know,

38:51

and the thing that how saves me the most time is like the

38:53

paranasal sinuses, you know, like often non, um,

38:59

uh, you know, non-contributory

39:00

or less contributory, um, perinasal sinus disease.

39:03

Um, so stuff like that. Uh, let me just see if I can,

39:06

you know, so, you know, these sorts

39:09

of strategies can be pretty helpful, um, for, you know,

39:13

the sort of studies that are high volume in your practice

39:15

and, and trying to, you know, build out tools

39:18

that make you have to expend less effort.

39:20

And all these, by the way, are available online for download

39:22

and important to your system

39:23

if you happen to use PowerScribe.

39:25

Um, so this is just an example.

39:27

Let me fast forward here a little bit.

39:28

And this is me again, clicking through

39:31

a CT of the abdo pelvis.

39:33

No, I'm sorry, of a chest, abdomen, pelvis.

39:34

But I'm just showing you that literally every line has, um,

39:37

everything that I would say commonly, um, uh,

39:43

you know, as, as an option.

39:44

Um, I'm gonna show here briefly a tool

39:47

that we developed our institution where for, uh, you know,

39:51

a lot of people use powers scrap,

39:52

and, you know, there's that clinical guidance tool down

39:54

there, which people don't use

39:55

that frequently at my institution.

39:57

Um, but he, at my, you know, but

40:01

because it's like really annoying to click

40:03

through the 20 things they ask you to do, we developed,

40:05

really, I developed and then helped

40:07

disseminate our eye institution.

40:09

A macro you just say like macro incidental,

40:11

or you can directly call something like

40:12

macro gallbladder polyp.

40:14

And then you can pick from a list of the imaging

40:18

and patient feature.

40:19

So here I'm showing the FLECHNER criteria, this, a lot

40:21

of institutions have something like this,

40:22

but basically he, uh, uh, where I am, we built out,

40:27

um, pick lists for every single, um,

40:30

see here the most com I think it's probably the most complex

40:33

one, the one for pancreatic cyst, you know, um, you know,

40:36

instead of having to go through the five charts

40:38

and go through the, you know, the white paper to really know

40:40

what you're doing, we just have like a nice, you know,

40:43

call one macro click on a, on a list or two, um,

40:46

and then you get the appropriate recommendation with a,

40:48

with a, with a reference.

40:50

So that really helps in these kind of niche, you know,

40:53

scenarios where you're, where you're encountering a need

40:55

for, um, uh, reporting incidental findings and,

40:59

and that that can be a headache if you're, you don't,

41:01

you know, um, uh, for some difficult things.

41:04

You know, I'm, I'm clicking through here a number

41:06

of different boilerplate language that we use, um,

41:10

in scenarios where you, there's a hedge, um,

41:12

where we're trying to provide a hedge that, hey,

41:14

this exam is not great for this scenario.

41:16

Um, it's motion degraded.

41:17

So these are all, anytime you're saying the same sentence

41:21

or two again and again, it's pretty helpful to, um,

41:24

create a macro.

41:26

We also have things that I find that I look up frequently.

41:28

We have as reference macros

41:30

or information, like I paste guidelines and,

41:33

and notes to myself and some, you know, into PowerScribe.

41:37

And I have these available. It's just easier to do,

41:40

to look at something that I've already have built.

41:42

Um, and it's just accessible in a little panel than

41:45

to Google or, or,

41:47

or bring it up in a browser in some other fashion every

41:50

single time or, or frequently.

41:52

So that's, those are, these are other potential strategies.

41:55

Um, you know, so here's just a, again, a review

41:58

of those key features, um, that are are helpful in,

42:01

in building out templates.

42:03

Um, we,

42:04

and we typically try to have, you know,

42:07

nicely built templates for as many exams as possible.

42:10

Um, and, um, I, I will say briefly,

42:13

'cause we're coming up on the end here,

42:14

I've got maybe another five minutes, is that there are a,

42:17

there's a lot more, I, I'm covering kind of the basics,

42:20

but, um, you know, there are ergonomic principles about

42:23

where your eyes should be on the screen, the angles.

42:26

You know, if you do this work for a long time at, you know,

42:29

your, your, this is a, this is a potentially sedentary job

42:32

that where you are, uh, at risk

42:34

for developing repetitive motion injury

42:36

or stress injuries, right?

42:38

Um, you know, there's all sorts of a available

42:42

hardware modifications.

42:44

I won't go into the depth of that,

42:45

that's like a whole nother topic in and of itself.

42:48

Um, I will say that my setup is very incidental to my,

42:53

uh, what is a avail, what I'm allowed to use

42:55

because of our IT environment.

42:57

I use a right-handed mouse with like, I don't know,

42:59

it's like eight programmable buttons.

43:01

I just use our default.

43:02

You know, I actually quite like our default,

43:05

so I don't have like a smart keyboard,

43:06

but I, every single key is programmed.

43:09

I have additional keys that are programmed

43:10

to help me navigate the computer.

43:12

And, and, um, and then I actually, if I, if I could,

43:15

I'd probably use an offhand device

43:17

that has programmable keys and a scrolling capability.

43:19

So a nice thing to have is to be able to scroll on your,

43:21

with your non-dominant hand to kind of relax

43:25

if you're working a lot, the dominant hand.

43:27

Um, and then, so I, I actually scroll

43:29

with a left-handed mouse as well when I, you know,

43:32

with program LA Keys that allow me

43:33

to access all sorts of functions.

43:35

Um, so thinking about

43:37

how you can bring in

43:38

additional tools would be pretty helpful.

43:40

Um, there are advantages to, um, uh, there are,

43:45

you know, and I covered this elsewhere, um, there are tools.

43:49

One of them is outta hotkey

43:51

to basically build automation into your, into your work.

43:54

So I have a tool where I have basically

43:56

automated all the things I do for every study.

43:59

So they, it brings up the prior report.

44:01

It, you know, it puts the comparison dates in, it navigates

44:05

through my EHR with the click

44:08

of the buttons you can navigate motions on.

44:11

So that's like another level of efficiency built on top

44:14

that's like a little bit more, uh, advance.

44:16

It requires a little bit more, um, upfront investment,

44:18

but that is a thing that can be done as well.

44:20

Um, building, you know, and then in institutions

44:23

and in teams having, um, uh, what is it, you know?

44:27

Oh, and then also I should mention that, that,

44:29

that when I report at my remote workstation,

44:31

and a lot of people, I don't use a power mic.

44:34

I use a, a freestanding

44:35

microphone that just sits on the computer.

44:36

So I just talk to the, the screen,

44:38

or I just talk to the room and

44:39

it picks up what I'm saying, right?

44:41

Um, that can be facilitated with auto hockey

44:43

and use other tools.

44:44

And then f figuring how we build out, um, different roles

44:48

and radiologists team can, and,

44:50

and improve the infrastructure

44:51

of teams can be very helpful as well.

44:53

Um, I will say also there's,

44:56

there's a little bit of literature on this.

44:57

Um, you know, there's just so many components of how,

45:02

how we can kind of, uh, improve our efficiency, improve the,

45:06

the benefit, um, to ourselves

45:08

and reduce the, the, the kind of inherent occupational risks

45:11

of being a radiologist.

45:12

It's a, it's a desk job, just like many others.

45:15

Um, and it's bad for your health to be glued to a, uh, uh,

45:19

a workstation for X number of hours a day.

45:22

You know, there's some literature showing out there

45:24

and, uh, um, that actually it, the people, uh, you know,

45:28

taking breaks, walking away from the

45:30

workstation is very helpful.

45:31

Actually, at my institution, quite a number of people,

45:33

myself included, uh,

45:34

we actually have under the desk treadmills,

45:36

and there's a, actually an amazing anecdotal,

45:39

but there's a quite a correlation between people who try

45:42

to stay moving during clinical work, um,

45:46

and their ability to move through cases.

45:47

Um, uh, it's really important for long-term wellbeing,

45:50

and there's been some evidence that it does not

45:52

compromise your ability to do the work.

45:53

Um, and it actually speeds you up,

45:55

like being physic physically active as we do our work, um,

45:59

really can, you know, blood flow to the brain

46:01

and all that sort of stuff,

46:03

and avoiding white matter hypodensities in ourselves is, uh,

46:07

is, uh, you know, is gonna be important

46:09

for our long-term wellbeing as well as our productivity.

46:12

Um, uh, let's see.

46:14

And I, I certainly leverage these

46:16

all myself when I'm working remotely.

46:17

Um, you know, my, my home workspace

46:20

and, uh, home office has an on the desk treadmill

46:22

and even a stationary bike.

46:24

And basically, um, uh, you know, uh, blunt in the impact of,

46:28

of, of, of these potentially negative consequences

46:31

of being at a desk all day.

46:32

And it makes a huge difference in terms of productivity, um,

46:36

uh, as well as various other, uh, you know, strategies

46:39

to improve your physiologic state to do the work.

46:42

Um, uh, in addition to practical strategies,

46:45

a certain mindset, you know, across every dimension

46:47

that could potentially influence how we do our work.

46:50

It's something to think about. Um,

46:51

I would advise people to think about this.

46:53

Um, so what's gonna come for the future?

46:55

Um, there are, you know, advances in tools.

47:00

It's been shown that certain AI applications

47:02

can make us a little bit faster.

47:04

Um, there are other reporting softwares out there.

47:07

My own institution is,

47:09

is will be likely switching up within the year to see if

47:12

that improves our, uh, systems, uh, efficiency.

47:15

Uh, basically, um, you know,

47:19

this is like a whole nother conversation,

47:20

a whole nother talk, but just to put your mind to the idea

47:23

that there are new tools coming down

47:25

and being willing to adapt, um, uh, take them on

47:30

and under, you know, try to automate the boring parts of

47:33

what we do, the repetitive parts

47:35

and focus on the high level work will make us more, uh,

47:38

impactful, um, improve our productivity, our impact,

47:42

and maybe beneficial to our work-life balance,

47:45

compensation, et cetera.

47:47

Right. Um, there it is.

47:49

That was quite a bit, uh, to cover in this short time.

47:52

Um, uh,

47:54

and, uh, you know, we, um, you know,

47:59

I'll take questions, discussions, um,

48:01

in, in the time we have left.

48:02

I will also provide, um, I've got quite a few, you know,

48:06

all the macros that I use in my, uh, uh,

48:09

are available online Okay.

48:11

At these links. Okay.

48:14

Um, I've started, it's,

48:16

it's actually still under construction.

48:17

It's not, it's the, the material there is not great,

48:19

but some teaching videos around this.

48:21

I'm gonna use this for our own own institution.

48:23

The book that I referenced is available as paperback

48:25

and ebook, and there are other

48:27

learning resources available here, um,

48:29

where I've collected together, um, free chapters from books,

48:34

um, other links to things.

48:35

And, and if you have specific questions

48:37

or you think that I could be helpful

48:39

for you in a collaboration, um, if you want me to, you know,

48:43

um, uh, if, uh,

48:46

have me serve in a consulting role in some sort of way

48:48

to help you or collaborate on an academic work, um,

48:52

feel free, feel free to, to reach out and ask you questions.

48:55

I'm here, uh, to be a service. Okay.

48:57

Well, thank you so much. And we can

48:59

move to the q and A session.

49:01

I hope we've left enough time.

49:02

We've got about 10 minutes, I think.

49:03

Yeah. Thank you so much, Dr.

49:05

T for, uh, sharing your slides with us today.

49:07

Uh, there is a comment in the q

49:10

and a that asks to show the PAC short key slide again.

49:14

Oh, yeah. If you're able to pull that up.

49:16

Yes. So my pacs is visage

49:21

and everyone's is different.

49:23

So, or people will have differing, um, uh,

49:27

let's see, where was it?

49:29

This, this one.

49:30

Um, so for those who work in the same packs as I,

49:35

there's a hot key just to bring up this panel

49:38

and it's just control K in visage, that's the default.

49:41

But in a lot of ones you can click on the toolbar

49:44

or wherever and you can bring, you know,

49:45

if you can't find it, you can search the documentation.

49:48

You can bring up a thing oftentimes that reassigns, um, uh,

49:53

tool so that, that can be helpful.

49:55

Um, yes.

49:59

Awesome. Yes, we have quite a few

50:01

large comments in the q and a.

50:03

Okay. Uh, but there is a question towards the bottom.

50:07

Which freehand mic do you you use? Is it very sensitive?

50:10

And any other idea

50:11

for left-handed scroll different to a mouse?

50:14

Great. Okay, perfect.

50:15

So, um, uh, let me answer, I,

50:19

and again, it's incidental.

50:21

I'm, I'm not endorsing anything.

50:22

I don't get paid by any company.

50:24

I use a road, it's called RODE, Mike, it's freestanding.

50:27

Um, some, I think one of my colleagues also has that mic,

50:31

or a similar mic on a, on an arm.

50:33

So I have it just sitting and it's, it's pretty good.

50:36

I, I can dictate from across the room.

50:39

I can stand in one corner and I can report not

50:41

even close to my workstation.

50:42

Uh, amazingly I can play music and it, and I think maybe

50:47

'cause the audio, the quality somewhere

50:48

between the microphone and PowerScribe.

50:51

I can play music and it can,

50:53

and I can dictate at the same

50:54

time and somehow it still works.

50:55

Um, so it's not perfect of course,

50:57

and that's why I have so many pick lists I try to avoid.

50:59

Um, but that's, uh, a good, a nice thing.

51:02

Um, if you go to the resources, um, link I

51:06

provided, um, there is a link there that provides links

51:10

to a whole bunch of options and thoughts on offhand devices.

51:15

There are. So if I go back to the offhand devices, um,

51:18

thing here, uh, you know,

51:22

I have used a pad.

51:23

There is, I think this is made, this one is made by Razor.

51:27

I can't remember what this one's made for.

51:29

Um, these both have scrolling capabilities.

51:32

Um, this is very, uh, you know, um, I've used

51:36

to use a, I can't remember the brand here,

51:39

but just a keypad,

51:40

but I really want to be able to scroll on the left hand.

51:42

So, and, and truthfully on the left hand,

51:44

my left-handed mouse, this is pretty uncommon

51:46

to use a left-handed mouse that's pretty atypical.

51:48

Um, I just happen to like it.

51:49

Um, I, I actually use the mouse wheel more often than

51:52

actually moving the mouse around.

51:53

So that's just one strategy.

51:55

Um, okay, let me,

51:57

lemme see if I can answer some other

51:59

questions here in the time we have.

52:00

Um, oh, we've got like eight minutes. That's not bad.

52:03

Um, let's see.

52:06

Uh, da da, let's see.

52:11

I, I, you know, I, I, I don't know my RV use for hour,

52:13

but I'm definitely one

52:14

of the fastest radiologists

52:15

in my system, I'll tell you that.

52:16

And, and actually it's, it's actually more important to,

52:19

it might actually be more

52:20

important to be fast for your setting.

52:22

'cause it might be advantageous

52:23

to be the fastest person in a

52:25

group of people who are not as fast.

52:26

So, I mean, I like to disseminate and help everybody,

52:28

but it's, it's, it's nice to stand out

52:30

and it's Earl's, actually, let me tell you,

52:32

I started this whole thing in part to help people who

52:35

are at risk of falling off the lower end.

52:37

You know, it's great to be super efficient

52:39

and be helpful for your, um, uh, um,

52:44

you know, super efficient and,

52:46

and, and, and, and self benefit.

52:47

But I, I made this in part

52:48

because I saw friends struggling

52:50

with this when they transition to attending hood.

52:52

And I, and I just noticed that people

52:53

who think about this make a big difference.

52:55

So, um, I, I would say, you know, this is something

52:57

to focus on for that reason.

53:00

Um, I will say down at the bottom of the chat, um, yeah,

53:05

I mean, someone has put a,

53:06

a large comment about

53:07

hanging protocols and that's super helpful.

53:09

Definitely. Um, search pattern strategies. Oh, it's amazing.

53:12

You would ask that. I wrote a whole book on search patterns

53:14

and in, you could just search long two search patterns.

53:17

And I, and I, and there's free online teaching videos.

53:20

You could just search search pattern teaching videos.

53:22

And I literally have, uh, you know, um, uh,

53:27

created teaching videos

53:28

for like the 50 most common studies in radiology.

53:32

Uh, and there's books and then there's online resource.

53:34

I mean, that's certainly, um, a thing, um,

53:37

that's available a lot of it for free actually.

53:40

Uh, and I do think that, okay,

53:42

and I will say it's an important caveat

53:44

to answer this question, um,

53:46

are some people inherently fast?

53:48

Um, I do think that there is a Modi component to, uh,

53:53

efficiency and then there's things that are harder to modify

53:56

or potentially not modifiable.

53:58

Um, definitely there are people who

54:01

leverage a minority strategies,

54:02

but they're just really efficient, right?

54:04

They think fast, they have fa,

54:06

they come with differentials quickly.

54:08

They, um, there's definitely

54:11

that variation that is inherent.

54:13

What I would suggest is that for each of us,

54:15

there is a range of modifiable,

54:18

um, kind of variation.

54:21

We, each of us, it's advantageous to focus on where in

54:25

that range we can, you know, move the needle for ourselves.

54:28

Um, one of the things, you know, that's a little bit,

54:32

that was a little bit beyond the scope

54:34

of talking about this was that if, for people

54:37

who are early in training, I've come to think

54:39

that also think that like people who,

54:41

like when they see findings and then they kind of hem

54:43

and they haw, they, you know,

54:45

we use the word perseverate on things

54:47

that tends to slow people down.

54:49

Building a knowledge base that allows you to

54:51

recognize things that you commonly see

54:53

and have a differential ready

54:54

or have a way of, um, you know, uh, uh, of,

54:59

um, uh, what is it, uh, you know,

55:03

spitting something out is, is very helpful.

55:05

And I, yes, second, the fact that chat, GBT

55:08

and various other now, um,

55:10

AI applications can really help you build

55:13

prompts for auto hockey.

55:14

Um, if you are interested in going down the rabbit hole,

55:17

like the ability to build automation on top

55:20

of your work is unbelievable.

55:22

Um, you can go as far as you want.

55:24

There is definitely a point of diminishing returns.

55:27

I, um, for, for all of this,

55:29

I definitely have built like these extremely complicated

55:32

reporting templates where like, where like

55:35

with like nested macros inside of nested macros

55:38

where I can like, you know, with like one

55:41

or two clicks, bring up any device

55:43

that you can put into the body

55:45

and then wear the device position.

55:47

But then I realized I don't even use it that often.

55:49

So there's definitely like, you know, going

55:52

to deep down the rabbit hole, you know, may not get you, uh,

55:56

as far as you'd like, um,

55:57

or may not have additional further marginal utility,

56:01

but there is quite, you know, it's helpful

56:05

to go a certain distance.

56:07

Um, let's see, uh,

56:14

yes, and I a hundred percent agree with, um, someone, uh,

56:18

John who has said that being able to remove the need to,

56:22

to free dictate numbers into power, into ultrasound reports.

56:26

I a hundred percent, um, uh, agree, uh,

56:30

at our institution we have some automated things.

56:32

In fact, I am of the thinking,

56:34

and it is gonna be a, of, one of the efforts of my early

56:37

career is to somehow try

56:39

and get the a CR to release a communication document

56:42

where you don't have to measure things in

56:43

ultrasound in three dimensions.

56:44

If it doesn't matter if it's normal, why are you report,

56:47

you know, you know, like our institution,

56:50

we still measure normal things on ultrasound.

56:53

Why? I don't know, you know,

56:54

I'd love it if we have has some default boiler plate

56:56

language for things that, that are non-contributory

56:59

to patient, um, management.

57:01

Um, I'll say briefly in response to, uh,

57:04

this last question here, an emergency radiology

57:06

fellowship, it can certainly be helpful.

57:07

Um, is it, uh, is it, um, necessary for everybody? No.

57:12

Um, but it can certainly be helpful In our institution,

57:15

we have an emergency radiology fellowship.

57:17

Um, I actually did one, um,

57:19

in part wrapped into a whole bunch of research stuff

57:21

that I did too, um,

57:23

and helps me kind of practice in emergency and in neuro.

57:26

Um, but a lot of people, most of our, most people

57:28

who practice generally in, in, in emergency, uh,

57:30

have not done a specific fellowship.

57:32

Um, though it is, you know, it'll,

57:34

let's just say it's helpful for some.

57:36

Um, and, uh, okay,

57:40

so I think we're nearing the end.

57:42

Let me just scroll again to, oops, let me just bring this,

57:46

go all the way to the end

57:47

and bring up the, uh,

57:52

the resources one more time just for anybody who wants,

57:55

if you want screen cap or whatever.

57:58

Um, uh,

58:00

and, uh, I, you know, it was, it's, it's great to be able

58:03

to be here and talk to you.

58:05

Um, and I hope you got something out of this.

58:07

Um, you know, I think a lot of things we've covered are kind

58:09

of basic, but, you know, the, the,

58:10

but some of these are things that it's easy to forget, um,

58:13

to, to try to leverage.

58:14

And, and I hope, um, if, if, if nothing else

58:17

that this serves as, you know, this talk serves as a prompt

58:21

to bring our attention to this key set of skills, um,

58:25

and to, and to look to develop those. Okay. Um,

58:29

Awesome. Thank you so

58:30

much Dr.

58:30

Tu, for being here and sharing your lecture with all

58:33

of us today and taking the time to answer questions.

58:37

Okay. And thanks to all of you

58:38

for participating in our noon conference

58:40

and asking great questions along the way.

58:42

You can access the recording of today's conference

58:45

and all our previous noon conferences

58:46

by creating a free account.

58:48

We'll also email out a link to the replay later today.

58:53

Be sure to join us next week on Tuesday,

58:55

December 10th at 5:00 PM Eastern, where Dr.

58:58

Sally Aisa will deliver a lecture entitled Introduction

59:02

to Pet Imaging of the Brain.

59:04

You can register for it@mrionline.com

59:06

and follow us on social media

59:08

for updates on future noon conferences.

59:10

Thanks again, and have a great day.