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Knowing Normal: Experience Vs. Reading Books in Radiology

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A few weeks ago, I was looking at a stream of comments on one of the social media outlets. And, as the conversation flowed between residents and attendings, I noticed one big distinction. The attendings tended to emphasize the importance of seeing thousands of cases to understand the meaning of normal. While, at the same time, the residents talked much more about books and case review series.

Within my residency program, I also notice a similar discrepancy between the resident and faculty opinions on learning normals. Therefore, I figured since both parties vary so widely on this topic, this would be the perfect forum to discuss the conflict. Here we go!

How Can You Best Learn Normal In Radiology?

To understand all of the normal variants out there in the world, essentially, you would have to practice radiology for hundreds of years. And as much as I love “thorough” books like Keats, they do not cover even half of the normal findings on plain film that you can easily confuse with pathology. Also, Keats does not include CT, ultrasound, MRI, mammography, or nuclear medicine. Since you cannot find all the normal variants in the literature, reading lots of books alone, in my opinion, does not enable you to learn enough to become proficient.

Additionally, if you are reading a book without context, the information inside rarely sticks. I know that if I were to go through the entire book of Keats without any real-life images, I probably would not remember all that much.

This point brings me back to the the essence of this article. How do you best learn normals? To maximize stickiness, I believe looking at lots of realtime cases within books, like Keats at your side, and/or having an attending sit next to you, allows to you to remember and understand normal variants the best. Context is key.

Reading Lots Of Films: Painful But Necessary?

In addition, it is not just about knowing normals. You also need to read scores of films rapidly to identify the normal variants appropriately. There is no room to perseverate forever on every case you read. Rapid assessment of normals has become critical to thriving in a bustling private practice.

In fact, you cannot practice radiology without reading tons of cases with normal variants unless you find yourself shielded from lots of films within a large academic center or you decide on an alternative career path. So, we recognize that you need to start reading early on to produce lots of insightful reports that differentiate normal as an attending. And, what better place than residency to learn these skills?

To that end, you may not believe it but most program directors do not derive pleasure in causing undue pain to the residents by saying you need to spend "x" hours on a rotation. Instead, we seek to make sure that in addition to reading books, you also read enough studies so that you can sufficiently identify normal versus abnormal. We want nothing more than to create an upstanding/quality radiologist.

What Is The Correct Balance To Develop A Feel For Normals?

Well, the perfect balance is very difficult to figure out and needs to be tweaked for the individual trainee and program. But, I would recommend spending a bit more time at work with your faculty instead of deciating too much time to studying in books.

Moreover, the government pays for you to perform clinical services. It’s hard to justify reading books when the Medicare pays you to work. And just as importantly, night time/post work tends to be the best time to reinforce your day’s learning.

The Bottom Line

Remember, you can always look at films by yourself later on in your career or while you are on call. But, you will not always have the advantage of a reading out with an experienced radiologist. So, I have to side with the faculty in this situation. Granted, I am a bit biased, but they make the best point!

Barry Julius, MD, is a board-certified radiologist at St. Barnabas Medical Center. He is the developer of an educational website. He is a 2018–19 Doximity Author.

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