What Does a Private-Practice Based Neuroradiologist Do?

Session 46

Dr. Narayan Viswanadhan is a community-based Neuroradiologist in the Tampa area. We discuss why he chose the community, what his day looks like, and much more. He has been out of fellowship training for three years now.

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[01:15] His Interest in Radiology and Neuroradiology

When applying initially for residency, he applied for internal medicine into several programs. And as he was doing his sub-internships, the was drawn more into radiology. What he likes most about internal medicine is coming up with the differential diagnosis. He likes figuring out the root cause of the problem. But as he kept going into internal medicine, he was going further away from it. And during his radiology elective, he realized he enjoyed being the diagnostician or the doctor’s doctor. And this was what drew him into radiology.

Moreover, neuroradiology got him as he was continuing his radiology residency. He enjoyed the anatomy and the complexity of it. He found it an elegant system and so he thought it was something he was fascinated with. And with the crossroad between technology, anatomy, and medicine, this is what made him go into neuroradiology.

Other specialties drew him were those with modalities overlaying with MRI. He enjoyed musculoskeletal imaging. He thought sports medicine was interesting since he loves basketball. They also had a strong training in body imaging and having that strong background, he thought it would be a good opportunity to do further fellowship training in neuroradiology.

[03:55] Traits that Lead to Becoming a Good Neuroradiologist

Narayan thinks that you initially have to have a strong knowledge base with a detailed and comprehensive understanding of anatomy. There are so many anatomic structures you have to be aware of.

Additionally, you have to have a good background of anatomy, physiology, and pathology. Narayan thinks radiology is a long residency which takes seven years in total. Attention to detail is also another critical thing. You need to think about not just common stuff but esoteric stuff can easily come into play which makes a big difference in patient outcomes. You also have to be an effective communicator. You will be working into interdepartmental conferences with neurologists, neurosurgeons, primary care doctors, ENT doctors, and oncologists. So it helps to have that personality that can effectively communicate. It’s nice that they can feel you’re somebody they can go to and rely upon to provide the best care for the patient.

[06:05] Community versus Academic

Narayan was actually torn between going into community and academic settings since he applied to an array of both settings. He did a two-year neuroradiology fellowship. People who do this are more inclined to do academics. And he actually thought this was the career path he was going to choose since he enjoyed working with other residents, medical students, and fellows.

However, he felt he was going to miss a lot of the aspects of radiology that he grew to love including body imaging and procedures. So while he thought of both avenues, in the end, he didn’t envision a career where he was going to focus on one sub-specialty for the rest of his life. And this is because he enjoys all the different aspects of medicine.

[09:15] Percentage of Practice, and Patient Types

Narayan explains that the beautiful thing about being a neuroradiologist working in a general setting is that while he has a niche, he also has the ability to a little bit of everything. This is from a diagnostic standpoint as well as from a light interventional standpoint. He feels he gets to utilize a little aspect of medicine he studied which still affects his day-to-day work.

As to what percentage of his practice is neuroradiology, Narayan would say that a third of his time is focused on neuroimaging. This includes reading MRI, brain CT, advanced imaging. Sometimes they do some profusion at some of their hospitals.

A significant percentage of the cases they read are patients with back pain (surgical or low back). Other patients that go in have issues with headaches and trauma. When he was still doing residency in Albert Einstein Medical Center in Philadelphia, they saw significant amounts of bullet-related and other types of trauma related to that setting. But now they see more of motor vehicle accidents. So their bread and butter would be routine imaging.

Moreover, they also have a cancer center. They have a neurooncologist in the community. So they see cases like gliomas and glio tumors, both initial presentation and follow up on those patients. This can include different therapies as well as evaluating and monitoring responses to treatment. Other cases are demyelinating disease and disorders like followup temporal progression or response to therapy.

From the ENT standpoint, they typically see patients (pediatric and adult) for hearing loss. They get CT for the temporal bones or MRI of the internal auditory canals to look for varying causes. They also see head and neck pathology such as tumors of the oropharynx or upper area digestive tract and after-treatment followups. These being said, it’s a broad scope amidst a focused niche.

But Narayan points out that even in the community, clinicians and consultants prefer neurologists to lead specific studies. Because of that added level of training, it significantly impacts patient care.

[12:36] The Impact of Neuroimaging Mimics

Narayan is doing a lecture for radiology assistance and one of the things he has in the training is neuroimaging mimics. This could have a significant impact. One of the cases he would show is the case of  a subacute infarct which was diagnosed as a tumor. If somebody interprets it as a tumor, the neurosurgeon may do a craniotomy. But if the imaging can overlap that infarct, that’s a big difference in treatment.

Another area which can mimic a tumor is called tumefactive MS. It’s a demyelinating lesion but it looks like a tumor. And it does have some subtle imaging findings but it’s important for the radiologist and neuroradiologist to distinguish these things.

[14:14] A Typical Day, Taking Calls, and Work-Life Balance

Narayan describes his days as very varied at his practice because they rotate between hospital-based and outpatient practice settings. But since he tends to go about 50% of the time to hospitals, they will start with the inpatient list. Having a big practice, they have a big ER and inpatient mix. So if he’s just assigned to ER rotation, he will just focus on ER. But his typical day would be reading anywhere from 100 to 150 studies.

In his current practice, a third of it would be neuroimaging related studies which include CTs of brain, MRI of the spine, the temporal bone, the head and neck imaging, tumor followup. The rest of it would be bread and butter – abdominal pain, pancreatitis, appendicitis, and other routine cause of abdominal pain and complications for patients and inpatient settings.

As a radiologist, he also does some light interventional procedures. He sees this as a nice break since he gets to interact with patients. He does paracentesis, thoracentesis, lumbar puncture, myelogram. He also does some biopsies at his particular setting. This is actually geographic in nature as to whether the subspecialty radiologist does this. But at his practice, even the specialty radiologist will do things like lung biopsy or participate on the drain.

Because of this mix, Narayan enjoys his day-to-day setting yet he still gets to concentrate on one particular specialty.

Narayan takes calls about once a month. They cover both days on the weekend. Because of the broad practice setting, they have many different physicians and many different types of call. But they’d typically go in and cover one set of calls, say focus on ER and others may focus more on inpatient and ER. Again, it depends on the location, the time of year, and the time of season. Nevertheless, he describes it as being quite busy. The volumes are high. Imaging utilization it seems can sometimes be high. Not to mention, they serve a large community so it makes for a busy day.

Narayan can say he has a good work-life balance. Having three kids, he sees them as his priority. And choosing this specialty allows him to spend time with his kids.

[18:25] The Training Path and Matching

Narayan’s great piece of advice is to try to be patient and try to reach that end goal at the outset. Take it one day or one step at a time. After premed, you do four years of medical school. Then you do a year of internship – either preliminary year in medicine or surgery or a transitional year. This is followed by four years of diagnostic imaging or diagnostic radiology.

During your third year of residency, you would apply for a fellowship in neuroradiology. It’s either a one or two-year fellowship. Narayan thinks majority of the fellowships are one-year training programs. But some still have two years.

In total, that’s seven years of training after medical school.

In terms of competitiveness in matching, it comes in waves. It also depends on some academic centers where some are more competitive than others. But by and large, most radiology residents will secure a neuroradiology fellowship. In his case, Narayan submitted a rank list for residency. And most students would rank within their top three or four choices. And most get between eight to ten interviews. So he would describe it as competitive but not as difficult as getting into medical school.

As a medical student interested in neuroradiology, Narayan recommends a few things to be competitive. It also helps during your fellowship interview to talk about certain highlights that you’ve had in the field that others may not have. This could mean participation in research related to neuroimaging. Narayan did a lot of posters and mini-abstracts related to neuroradiology he’d present at national meetings like the American Society of Neuroradiology.

So think about pursuing research-related activities or even educational activities. He went to a very strong didactic residency focused on residency education. He would teach junior residents and they would have medical students come and rotate. He would create lectures on certain neuro topics. There also had opportunities to teach the CT and MRI technologists different aspects.

[22:33] Bias Against DOs and Other Subspecialty Opportunities

Personally, Narayan doesn’t see any bias against DOs in the field. He doesn’t actually realize whether one is a DO or an MD since it’s not something that comes into fruition on a daily basis. That said, it doesn’t matter whether you’re an MD or DO.

Once you’re a neuroradiology fellow, other opportunities to further subspecialize include focusing on areas like functional MRI, profusion and imaging related to stroke or tumor, pediatric neuroimaging, pediatric neuoradiology, and pediatric neuro interventional radiology or neuro interventional radiology.

So three additional areas in subspecialization may be pediatrics, head and neck, or neuro interventional. For many people, after their one or two years of diagnostic neuroradiology, they would do an additional year of pediatrics. Or if they’re interested in doing interventional radiology, it’s an additional two years of interventional neuro training. There are also those that exclusively wanted to focus on head and neck, so there are some places you could do additional training for a year.

Moreover, in the practice setting, it depends on what path you want to create.

[25:30] Working with Primary Care and Other Specialties, and Special Opportunities Outside of Clinical Work

Narayan wishes primary care physicians to know that they’re trying to provide the best, high-quality reads for their patients. Sometimes, with the increasing turnaround time demands and increasing volumes, it can become difficult. But he always does his best to provide the most accurate report in a timely fashion.

But also, the more information neuroradiologists can have, the better report they can provide. If they could give additional history, this could be very helpful in localizing and targeting their search in finding pathology.

Other specialties they work the closest with include neurosurgery, neurooncology, and ENT doctors – being the three main areas they work with. Narayan also stresses that it’s good to have a good rapport with other surgical or clinical colleagues. A lot of times they’d just call each other on the phone. They frequently communicate so they can provide quick access to each other. Oftentimes, it helps to have that interdisciplinary relationship to further improve the care of the patient.

Narayan thinks there are many different avenues to pursue like the pharmaceutical industry. You can help to evaluate certain disease or therapies and drugs and response. Sometimes it’s helpful to have someone with an imaging background and taking that into the pharmaceutical industry world. You can help evaluate both drugs and other contrast agents in response to therapy. He has also met neuroradiologists who have taken on working in fields like public policy. That said, he thinks the opportunities are endless.

[29:11] What He Wished He Knew

Narayan says he wished he knew it was a pretty challenging road. He thought it would have just been something he was going to do. But he never really anticipated the number of years it would take collectively. He never thought about the number of examinations he was going to take. After the three steps to get into medical school, there were also three board examinations. Then there also used to be the notorious oral board examination. Plus, after neuroradiology, there was another subspecialty boards he took called the Certificate of Added Qualification (CAQ) in Neuroradiology provided by the Board of Radiology. But the unique thing about neuroradiology is the endless educational cycle where it never ends. He’s actually learning and reading to this day. And no matter how much you read or study, there’s just so much body of knowledge that continues to change.

Plus, in the advent of artificial intelligence, some people may be hesitant. But Narayan sees this as an interesting opportunity to work side by side to help AI make them more effective and more accurate. So although it’s an exciting field, he just didn’t think he was ready for all the challenges.

He also mentions a poster the ABR does that highlights the fourteen years of training that takes to become a neuroradiologist. It has the picture of the brain that shows each area and during which step they’re in. Indeed, it’s a long road but he’s still glad he chose it.

[32:43] Major Changes in the Future –  AI and Machine Learning

Narayan says that if there’s one body of people that are scared and thinking their field is going to end is radiology. But looking at their different radiology meetings and the leaders in their field, they’re actually embracing machine learning. They think of different ways to have it improved. They already have steps in machine learning in terms of working with them. He found that while it’s good in some areas, it has limitations inn others. So it just works in complement with the radiologist.

Majority of the time, he thinks it’s not the most accurate. There are some nuances to it that is not quite there yet. But there are definitely areas he can see where it can help them. This said, he thinks we should be embracing the leaders in the AI and tech companies. He thinks it would be nice to help the computer think about different algorithms and about the way they interpret the brain. Because some cases don’t always nicely fit into some sort of algorithm that a computer may be able to pick. But for day-to-day portable chest xrays, it’s a useful adjunct.

Also, as you do more and more and read more and more, you start to learn some subtle patterns.

[36:34] What He Likes the Most and Least

What he likes most about being a neuroradiologist is finding things on people that’s not always expected. He likes to provide the answer to a patient’s problem as early as possible. While many times it’s obvious to find something, it’s rewarding to find them. And really this affects the patient’s cure early on in the disease. A lot of times, they always look at the whole study. But in fellowship, he remembers reading the MRI, the lumbar spine for back pain. But he had to define a Wilms tumor in the kidney. And the patient was able to get that resected and cured. And sometimes, you’re the first one to notice that. He finds nodules when looking at shoulder xrays or just different pathologies all over. And the more you look, the more you find. So he finds this especially rewarding.

On the flip side, what he likes the least about his subspecialty is the difficulty of multitasking. You can be looking at a complex case and then you’d have to juggle that with taking a phone call from a technologist for instance. But he tries to resist the temptation to rush through things. So he just takes it one case at a time. That said, you still need to be able to multitask.

If he had to do it all over again, Narayan would still have chosen the same path. It goes in waves, but overall he’s happy the path he chose is a wonderful career. It’s one where you can have a tremendous impact on, both working with other clinicians and other doctors and also impacting the patient.

[39:45] Final Words of Wisdom

Narayan leaves us with some pieces of advice. Something he learned from his mentor is “we got to get the list cleaned up.” But you have to always remember that it’s a list of patients. It’s people’s individual problems. They’re going through certain conditions. So it’s your responsibility that while you need to get the work done, remember that they’re patients. It can easily get lost in that mentality of just cleaning up the work. Just stay grounded. Be patient. And try to learn and do as much as you can.

For the medical student, and you might already know you wanted to be a neuroradiologist from day one, it’s important to get knowledge in other areas. In fact, Narayan recommends that you do less in neuroradiology throughout your medical school and residency training. Because the more you understand what other specialties are looking for and what they want to know, the better neuroradiologist you’re going to be. Same thing with doing more. Increasingly, you’re going to be doing more procedures and be versatile. So doing your training, try to learn as much as you can.

[41:46] Like This Podcast?

Did you enjoy this episode? Shoot me an email at [email protected]. I welcome any suggestions or specialty that you would like to come on the show. Better, send me a name so that I can interview him or her.

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