Last week, Ryan Schultz, Winnie Lo and Randi Drees wrote about how they approached studying for the board exam. This week, in part II of the interview, they talk about their favorite resources, and top tips for preparing for the exam. Although these articles are about the ACVR exam, the ECVDI exam is very similar in content and format. There should be plenty of helpful advice that’s applicable to everyone!

AZ:What were some of your favorite resources (books, websites, etc)?

Ryan:

By far the best were real good cases with a known follow-up and then going over other differentials for what it could have been.

Randi:

I really like my paper summary collection, that is a great resource.

Winnie:

I found that “The Handbook of Small Animal Radiological Differential Diagnosis” by Dennis et al to be a useful summary of differentials.  Thrall was also a useful overview.

AZ:What are your top 3 tips for studying for the oral exam?

Ryan:

Practice making oral reports on real cases with known diagnoses.

Practice the structure of your report: Findings (+ summary of the pertinent ones if there are a lot), Radiographic diagnosis, Differential Diagnoses, Plan

Stay broad in your differential diagnoses (i.e. neoplasia or infectious and then narrow it down rather than say adenocarcinoma or abscess), learn the differentials you may not have seen in your residency and have memorized lists of differential diagnoses ready to spit out whenever you see something common (lung pattern).

Randi:

Make a clear list of differentials in your head to fall back on for all the sections. I liked to have that written, that I would have to have something to flip through between the sessions.

Make a clear system for yourself on how you are going to read the films and stick to it.

Practice oral exam sessions (mock boards).

Winnie:

See lots of cases on clinics.

Have a set of differential diagnoses for certain radiographic findings

Remember to correlate findings to history/presenting complaint.

AZ:What was the difference between studying for writtens and orals?

Ryan:

The good news is that it took A LOT less time to study for orals and there is much less memorization! Just PRACTICE and go over a lot of cases.

Randi:

Well, the list to study is not as well defined for the orals as for the written. And it is much more fun to study for the orals.

Winnie:

More reviewing cases rather than sit-down studying.

AZ: Do you have any other advice for next year’s residents?

Ryan:

Just read cases in the boards as you see them. A lot of cases were a lot easier than I was expecting. So don’t overread them.

Randi:

Find yourself something to do to clear your head inbetween the exam sessions. I had up to 5-6hrs between sessions and you can’t really study in that time. I flipped through my differential lists, went running for 2hrs, something like that.

Try to be relaxed and READ THE FILMS, READ THE FILMS, and dont forget to READ THE FILMS in the sessions. The problem is that you won’t get any feedback during all the days of the exam, as you may be used to on the clinic floor or from mock boards. So just believe you are right (you may have to be a bit sarcastic about this now and then and don’t worry about your screw-ups, that keeps the spirits up over the 3 days. These days are exhausting enough, so you don’t need to worry on top of things about the mistakes that you for sure will make, or not if you are truly brilliant.

After the written exam is done, the radiology residents start preparing for the oral (certifying) exam. This is a long exam, broken into several parts over two or three days. It’s quite different from the detail oriented written exam, and focused on putting all of that information together for interpreting imaging cases. I asked Ryan Schultz and Winnie Lo from UC Davis, and Randi Drees from the University of Wisconsin, Madison, to give us their perspective on how to prepare for this portion of the exam.

AZ:How many months ahead of the exam did you start preparing?

Ryan:

I guess I started preparing with KCCs the first year of the residency, but specifically I started studying for the oral boards about July (2 months before).  I needed time to recover from the writtens first.

Randi:

2 months minus 2 weeks for ECVDI meeting travel = 1.5 months study time.

Winnie:

I started earnestly preparing about 2 months before the oral exam.

AZ:What did you start with and how much time did you study per week?

Ryan:

I started by having faculty members present about 2 cases once a week and really trying to improve my report style by making it more concise.  I was used to spending a lot of time on findings and then thinking over all the differential diagnoses in KCC. When preparing before the orals I would be very thorough on the findings (so as not to miss subtle lesions at the edge of the film) but would make a timely list of 1-3 differential diagnoses in the order I thought was my likely.  I did this for about a month before boards while also skimming over books on differential diagnoses and contrast studies which I hadn’t seen much of (just looking at images and reading the descriptions).  The month before the boards I would practice making oral reports on a couple cases at a time at least 2-3 times per week with other residents or faculty.  I also practiced making oral reports and talking to myself the remainder of the weekdays (go somewhere where no one else will hear you – but it really helps, otherwise when I’d read the answers on cases I would believe I would have said some stuff that I may not have).  The week just before boards I practiced making oral reports on cases in front of people everyday for maybe an hour.

Randi:

I started with a “quick” re-read of Thrall that took a little longer than anticipated, and typing up a list of differential diagnosis from that per chapter. I was full time on clinics between the written and orals, hence study time was not much more than 1 hr during the weekdays and maybe total of 8hrs on the weekends.

Winnie:

Preparing for orals was very different than for writtens.  I didn’t really have any sit down sessions to study.  I did spend about 2-3 hours going over old cases in our archives.  Mostly it was being on clinics and seeing cases.

AZ:What was your approach to studying? (journals, cases, mock orals, any software, etc)

Ryan:

I mostly went over a lot of cases; digital, hard copy and on the ACVR website.  I also looked at a lot of images in a book or two on contrast studies.

Randi:

I had read the pertinent veterinary radiology books at one point in my residency, however as my memory sometimes tricks me in deleting important details I did a quick review. As stated above I started with Thrall, making myself a “rescue” list of differentials in case of getting lost. For Large Animals I used Butler as baseline knowledge, for US Nyland / Matoon (both of which I had summarized at some earlier point) & Penninck / d’Anjou. Reading titles & looking at pretty pictures and figure legends is great as a refresher. I topped that up with flipping through other radiology books that were available in our department library.

I had previously summarized and copied title / abstract / pretty pictures the papers of the recent years to a single page per article and went through those on the weekend before the exam. That was my baseline especially for CT / MRI, as this is still marginally covered in books at this point. For NucMed I used the handbook and my paper summaries.

For artifacts I went down the lists on the objectives and wrote a brief statement for each for appearance, cause, remedy. I tried to memorize those, my brain was a little resistant to studying & memorizing after the writtens, however I still could remember some of it during the exam.

The most important thing however were the mock board sessions generously given by my faculty and fellow residents. I had about 8 weeks of Mon-Fri 8-9am mock boards with 4-5 cases per session. It is pretty hard on the self esteem, but really worth it as it gets you in the swing of talking / thinking through consecutive cases in an organized fashion even if you have no idea what you are dealing with. And that is going to happen on the exam in one or the other way and that way I didnt get too thrown off by that then.

Additionally it is a very valuable and condensed one on one learning experience. I feel I have almost learned more in this short period than before in the residency, or lets say got more fine tuning on my skills. So if you dont have that in place, I would strongly reccomend to ask your faculty or fellow residents to do something similar for you.

Winnie:

I thought being on clinics was the best preparation.  Mock orals were also extremely helpful.  They helped me organize my thoughts and to practice my delivery in a concise and direct manner (getting in the groove, so to speak).  I also did review recent journal articles to refresh some topics in my mind.

Last week we started with some tips on preparing for the written board exam by Matt Cannon, Sophie Dennison and Randi Drees. The article covered the timeline for starting to prepare and dividing your time, as well as reviewing the literature. This week they cover their favorite study resources and the top three tips for studying for the written exam.

If you have tips for next year’s residents, please add them to the comments section! Everyone is welcome to contribute. As you can see from last year’s and this year’s interviews, each resident has a unique approach that worked for them. The more advice we can gather, the greater chance we’ll have of finding good advice to suit any study style.

AZ:What subject took the most time?

Matt:

Probably Alternate Imaging, just due to the sheer volume of information. The material is familiar because most of it is what we do on a daily basis, but there is a lot of associated literature and physics. I ended up making a decision early on that I would not get bogged down in the fine details of things like MR physics and instead be sure that I had a basic knowledge and understanding of the material to fall back on. I think this helped me avoid spending too much time on details that would probably never show up on the test anyways. For me, the easiest sections to study were Radiation Biology (there is only so much material to read on this subject) and Anatomy (again, it’s knowledge that we use daily).

Sophie:

Pathophys without a doubt.

Randi:

Reading the papers, including Phyisology & Pathophysiology. Physics went only fast bc I went though it in depth before.

AZ:What was the hardest subject to study?

Matt:

Pathophysiology, hands down. Studying for this section is like looking into a black hole. The objectives are nebulous and open-ended and the source material is varied and overwhelming. If you don’t set boundaries you could spend an infinite amount of time on each objective. Even after studying this section extensively, I still felt like 99% of the material I studied was not asked, and I’m still not sure where some of the questions came from. I wish I had better advice to give on how to prepare for this section, but if I had to do it over again I’m not sure what I could have done differently.

Sophie:

Pathophys – the objectives don’t really advise what level of learning is needed ie. organ level, cellular level, receptor level. So it becomes a little bit of guesswork and gambling.

Randi:

Pathophysiology, because it is very hard to determine where to set the limit, how in depth one may be asked.

AZ:What were some of your favorite resources (books, websites, etc)?

Matt:

Standard books I read included the NM handbook, Nyland/Mattoon, Thrall, Christensen’s Physics, Bushberg for CT/MR/Digital radiography, Kremkau for US, Hall for Rad Bio, Wallack for contrast agents, and Ettinger for pathophysiology. Other resources I found helpful were Slatter and Bojrab for surgical/bone stuff and pathophysiology, Radiographics review articles for MR/CT physics and artifacts, Dr. Kittleson’s cardio website via UC Davis (www.vmth.ucdavis.edu/Cardio/cases), Dr. Buchanan’s cardiac embryology website via UPenn, an MRI physics website at www.e-mri.org, and various review articles in Vet Clinics of North America and Clinical Techniques in Veterinary Practice. The online resident notes were really hit-or-miss. Sometimes they were great, but other times they were too detailed or not detailed enough.

Sophie:

Ettinger on line, I also went through Guyton before I started Ettinger back at the start of my second year, but not convinced that was really necessary although the background was good. Raphex physics exam and Huda for physics practice. WIKIPEDIA  – its amazing what shows up on there…but only trust the referenced stuff.

Randi:

Guyton for physiology. Zagzebski for US. Bushberg for general physics and radbio. Nuclear medicine Handbook. And my paper collection. Wikipedia. Google.

AZ:What are your top 3 tips for studying for the written exam?

Matt:

Plan ahead – I felt that having at least a loose study timeline was very helpful in keeping me organized and not freaking out, even if I didn’t always adhere precisely to the timeline. Starting a year ahead of time should be more than sufficient, even if you just plan to read a few hours each week. I actually made a 5 week timeline before the exam detailing how I would spend each week, and I think it prevented me from losing it.

Use the people around you – Before you start, ask older residents or faculty members what books/articles/resources they would recommend reading and what resources probably aren’t necessary to read. There is a lot of material out there and you can’t read it all, so having a game plan as far as what you are going to study is key.

Relax – It’s a cliché but you must do it. All the time you are really stressed out is wasted time. Everybody kept telling me that I would pass but I didn’t believe them and got stressed out and you probably will not believe them either. But the fact is that most residents pass the exam, although you will not feel that way when you finish. There are at least several sections that you probably could pass without even studying so that should make you feel better as well (although I don’t recommend trying this).

Sophie:

Start early – its easier to get in the habit of an hour or two a night and then step up from there rather than freaking out at the last minute and trying to get brain to engage.

Use other notes eg. the 2005 answers as a skeleton but make sure YOU can answer all of the objectives questions. Making a summarized version of your notes is a great way of giving yourself a ‘quick reference’ guide for the last couple of weeks before the exam.

Remember you are training to be a radiologist not an internist and gauge study to that.  I tried to study to the level I felt I needed to know on the clinic floor to answer most questions.

Randi:

Read as much as you can during your residency along the objectives. Read as many papers as you can during your residency, I found it easier to read by organ system than by year. Understand the physics at least halfway before you really start studying right before the exam.

Compile some kind of short form of the objectives for yourself to review. It is too overwhelming otherwise.

Sleep enough. Do lots of sports.

Every year radiology residents have to study a large amount of material on imaging physics, pathophysiology, anatomy, special procedures, alternate imaging modalities, and radiation biology in preparation for the written board exams. It’s a stressful time for residents in terms of deciding what materials to use and how to divide their time between subjects. Last year I interviewed three residents who completed the written boards, and got great feedback from those who were preparing to do the same thing.  You can read the 2007 interviews here:

Tips for Passing the Radiology Boards – Part I
Tips for Passing the Radiology Boards – Part II

2008 was the first year that the written exam was taken at the end of the second year, rather than in the third year of the residency. This meant that everyone had to be that much more organized in their strategy early on in the residency program. I interviewed two residents who successfully completed the written exam in 2008; Matt Cannon from UC Davis, and Sophie Dennison from the University of Wisconsin, Madison. Randi Drees from the University of Wisconsin, Madison, wrote the exam in 2007 and was kind enough to contribute her advice as well.

This week I’m publishing part I of the interview for you. Matt, Sophie and Randi share their timelines for studying and their approach to reviewing the literature. Next week you’ll be able to read part II, including the residents’ top three tips for preparing for the written board exam and their favorite study resources.

If other residents have tips for the exam, please post them in the comments section! You can’t have enough good advice from people who have been through the process, so I welcome your contributions to the conversation.

AZ:How many months ahead of the exam did you start preparing?

Matt:

I started studying lightly after Christmas during my first year. I also had several weeks off in the spring and summer of my first year that I used to organize material and begin studying. However, I also made it a point to read recent VRU and other classic articles from the beginning so that I did not have to cram too much in at the last minute. I found this practice really helpful from a clinical perspective as well. I began more focused studying of the exam objectives 4-5 months before the exam. I had 5 weeks off before the exam that I used primarily to review material and fill in any holes in my knowledge.

Sophie:

Actually I worked pretty much from the start of the residency to get up to date with literature and get back in the swing of pathophysiology, but 5 months before was the hard core summarizing notes and learning period.

Randi:

January 1st thorugh May 2nd, that makes 4 months.

During the Residency I had gone through some what I thought would be pertinent books such as Bushberg, Thrall, Butler, Zagzebski, Nyland/ Matoon, etc. And tried to read through the previously written objectives. And read some papers.

AZ:What did you start with and how much time did you study per week?

Matt:

I began by reading certain foundation textbooks and taking some notes on pertinent sections. I did this to get an overall understanding of the material, especially physics. The second time around I read with an eye toward answering individual objectives. Initially I studied for several hours in the mornings on weekends when I wasn’t busy or on-call. I treated off-clinics time like workdays for the most part, studying from about 9-5 with a lunch break. About 4-5 months before the exam, I began studying about 10-15 hours per week, in the evenings and on the weekends. During the 5 weeks before the exam, I spent each day as a full workday, studying from about 8-5. I then would typically take a break for dinner and then spend an hour or two in the evening reviewing the day’s material or studying anatomy ( I didn’t actually allot any days of studying for anatomy, as I figured this section would take the least amount of time and doesn’t require a lot of thought). During this review period, I spent 1 week each on pathophysiology, alternate imaging, physics, special procedures, and radiation biology. I had several days left over at the end for last minute review and memorization.

Sophie:

Pathophys, physics and literature; 1-2 hours a night of objectives study regardless of what other work needed to be done. Once within 5 months of the exam, minimum of 3 hours a night plus 4-6 hours each weekend day.

Randi:

I tried starting to just work down the objective list but there is repetition and not the chronology I liked, I figured that won’t work. I tried reading though the notes written up by previous residents, that is excellent supply, but I could not study directly from that.

Study time: I had 4 weeks off clinics before the exam.

• reading papers and supplying with Guyton / Ettinger / etc.: good 3 Month with ~3 hrs Mo-Fri, up to 10hrs on Sat / Sun during clinics time
• All physics including alternate imaging: 2 weeks in the off time (off time study time ~ 4-12hrs / day, depending on mood)
• Rad Bio: 2 days in off time
• Specials: 2 days in off time
• Anatomy: 2 days in off time
• Melt down: 2 days in off time.

AZ:What was your approach to reviewing the literature? (which journals, which years, any software, etc)

Matt:

As mentioned above, I tried to read VRU and other classic articles throughout my residency instead of cramming at the last minute. After reading each article I would write several sentences at the top of the article summarizing the basic gist and any essential points to remember. Therefore when I went back through the articles later I could quickly get a feel for the important points of the paper. When reviewing in the last several weeks I spent the vast majority of time reading the last 8 years of VRU. I did skim other journals including JVIM, JAVMA, AJVR, and Vet Surgery and read pertinent articles but I did not find this particularly helpful. Overall, I did not spend that much time reviewing literature and instead spent the majority of time reviewing the individual objectives.

Sophie:

I searched the last five years of JAVMA, JAAHA, JSAP and last 8 years of Vet Rad. If something sparked an interest then I looked up other refs using pubmed or google scholar search engines. I copied and pasted the title, ref and abstract plus any images which would spark memory onto a word doc page, printed the page and added hand written notes about the article to the sheet. This ensured I read the article, proved to me at a later date I had read the article and provided something for my mind to go back to when trying to recall information.

Example of Sophie’s literature summaries

Randi:

During the residency I had started to collect interesting articles in a simple windows file system, pdf’s filed by organ system. I additionally downloaded the last ~ 5 yrs of VRU, and imaging related things out of JVIM, JVS, JAAHA, JSAP, JAVMA, JVR and added that to the files. Then I started reading by organ system. With Adobe I copied title, abstract and pictures that I thought would help onto a single page per article and printed that and summarized on this page what I thought was important in handwriting. That way the highlights are on the pdf and I know where to find it, but I don’t have that overwhelming amount of papers to print out. Those summary pages made up about 4 folders in the end and are organized the same way as the pdf-files on my computer. Nice and handy. Reading the papers I covered a lot of relevant physiology, pathophysiology, anatomy and physics. Areas I felt weak on or couldnt answer an objective after doing this I supplied mostly with Guyton and Ettinger for pathophys. Doing all this took the longest time.

Physics: I had fought my way through Bushberg before, and that went very much faster for the real preparation as I anticipated. Same for NucMed, I used the handbook and papers. For US Physics Zagzebski, for MRI physics I read also books for technicians, they break things down a little more user friendly and applicable.

Special procedures: very good what’s written up in the previous residents notes, papers and books like Thrall.

Anatomy: looking at pictures in Miller and other Anatomy books and normal Radiographs in Thrall, papers.

I then I got some summarized notes (pretty and colorized, very soothing to the eye, and very good for memorizing) from one of my fellow residents. I took additionally about 3 days to write a short answer to all the objectives to make sure I know at least something for every one on the list and don’t miss anything.It is great if you manage to compile this huge amount of information into some smaller format, such as 2-3 folders. Otherwise I felt I sit in front of “extraordinary large piles” and can’t look up things fast or can’t even transport all that to where I was supposed to take the exam.

Well it’s only a few weeks until the oral boards! Here’s the final set of cases for practice. Email me through the web form for answers. For more practice, there are plenty of other cases to look at, just click on the “Cases” tab at the top of the page to access them.

Case 1

Case 2

Case 3

Case 4

Case 5

I just had an email from a new radiology resident, who was wondering how to get organized for the written board exam. I thought I would post links to some interviews of residents who recently took the exam (part 1 and part 2), and give some links to material. There are lots of resources available, including written notes on the ACVR resident site, review sessions from past ACVR meetings, cases, and literature (database of articles for download, or current articles online). The key is to get organized and make a plan so that you feel on top of things.  Feel free to email me or post comments and questions!

It’s time for a few more mock boards cases, focusing on the abdomen. Quite a few people used the mock boards thorax cases for practice. If you haven’t yet, try them and email me for answers.

This week there are 5 abdomen cases to look at. Make sure to look at the whole radiograph and use a systematic approach for your interpretations. Email me through the web form for answers.

Abdomen Case 1

Abdomen Case 2

Abdomen Case 3

Abdomen Case 4

Abdomen Case 5

Now that the written boards are done, veterinary radiology residents everywhere are thinking about the oral examination. I have quite a few cases collected on the MIRC site from the Case of the Day category, so I thought I would identify some for practice oral sessions. I highly recommend practicing your oral reports with a mentor or colleague to note what you say and how you structure the report. The art of the oral examination includes thoughtful organization, clarity and succinctness, as well as time management. Here are some suggestions on how to structure your readings.

We’ll start with the thorax. Try to complete this series of 5 cases in 45 minutes or less. Part of the challenge is to be able to put aside your worries of how you handled the last case and move on to the next one. Make sure to describe the first set of images and your initial differentials before requesting additional images. The answers are hidden, so if you would like the key once you are finished, send me an email through the web form. Of course, non-residents are welcome to try their hand at the cases as well. Good luck!

Thorax – Case 1

Thorax – Case 2

Thorax – Case 3

Thorax – Case 4

Thorax – Case 5

The topic for the resident review session at ACVR this year was abdominal imaging. Randi Drees, from the University of Wisconsin, attended the sessions. Here are some key points she thought were worth noting.

The resident seminar held exactly what the title implied: a REVIEW on clinical approach to abdominal radiographs. The session gave a very well rounded overview on reading abdominal films, and that means “read the films” and “know your basics”, which you will also find in the classic papers or chapters of some of the speakers, who did a great job.

There was no reinvention of the wheel, however some random facts which I picked up on were:

• A splenic torsion will displace the spleen laterally to the colon & duodenum.
• A right renal mass will displace the duodenum medially.
• Ovarian masses will move intestines medially, not necessarily ventrally.
• Seth Wallacks book was heavily advertised as summary of the contrast procedures papers up to the date of publication.
• Remember to think about adhesions in GI studies which display static position and shape of organs.
• Pancreatitis in the dog seems to affect the right lobe and the body more commonly where as in the cat left lobe and body seem to be more commonly affected.
• Ethylene glycol intoxication may cause opacification of the kidney due to precipitated mineral.
• Remember the left lateral as recumbency of choice in procedures which may cause gas emboli, that way the gas will get trapped in the right atrium or cause pulmonary embolus as opposed to systemic embolus.

The sessions are available on the ACVR resident website for those who would like to see them. You’ll need to log in with your ACVR user name and password.

Earlier this week, I interviewed three residents who successfully navigated the written radiology boards to find out their strategy. Here are the rest of the comments and advice they had for others studying for the exam.

AZ:What subject took the most time?

Sandy:

As far as objectives, Physics. For literature, probably the ultrasound lit

Mathieu:

Alternate imaging for sure, because of all the literature.

Lisa:

Physics–it’s a lot to digest and it isn’t something we actively use daily. Actually UNDERSTANDING physics rather than just recognizing the diagrams and reciting the theories takes a bit of time.

AZ:What was the hardest subject to study?

Sandy:

From a tactical perspective, I think Special Procedures, since there was no definitive text or resource other than the previous years residents notes. Physics was a difficult topic, and was the most time-consuming, but at least you knew it was all there in Bushberg or Christensen.

Mathieu:

Pathophysio… SO HUGE… and difficult to know what to study from… I think ideally Ettinger + Guyton but impossible to read everything!

Lisa:

Physics (see above) and Physiology (as the objectives are very broad and can be overwhelming)

AZ:What were some of your favorite resources (books, websites, etc)?

Sandy:

Bushberg: physics and RadBio
Blackwell-synergy: pdf’s of VetRad, JSAP, VetSurg
Bojrab: Pathophysiology of small animal surgical disease

There’s a good website from Penn on vascular ring anomalies:
http://cal.vet.upenn.edu/cardiosf/project/embprs/embryo.htm
UCDavis Cardio cases:
http://www.vmth.ucdavis.edu/Cardio/cases

And when all else fails, or even before you look anywhere eles, use Wikipedia.org. It’s
amazing what’s on that website and how in-depth it can get. Physics, medicine, anatomy,
physio, radbio…

Mathieu:

Bushberg! (My favorite, because I love physics although I know it sounds nerdy…) Dyce for the anatomy. Parts of Ettinger for pathophysio. All the literature on line (so cool to have access to all Vet Rad on the computer from home, thank you Dr Biery and the ACVR!, I don’t know how people have been able to do before, having to look for the different issues… ) The edited ACVR objectives, VERY VERY useful (thank you very much Allison Z and Silke H for all the work put into that).

Lisa:

Ettinger–e-edition (a good source for downloading images into a study format)

Bushberg Physics–not my favorite, but very useful and it does get easier to understand after reading the same paragraph 6 times!

GE Medcyclopedia website — a great source for concise definitions and images to download

Other residents — Made practice quizzes for each other, good support as well–knowing I wasn’t the only one taking it for a second time was helpful!

A just published book: Pathologic basis of Veterinary Disease (formerly Thomson’s special veterinary pathology)–concise, excellent images

By about 3 months prior to the exam I had put together my own study notebook with “cut and pasted images” (jpegs downloaded from websites, scanned images, and images taken from pdfs) along with my own notes written on the same page in eye-catching colors–this really helped me organize the info in a way that fit my learning style (I combined a lot of anatomy / special procedures / physiology stuff together–this gave me a way to remember some of the little facts easier as they were “in context”) For example–I had a section on the kidney that included diagrams of the microscopic structure of the kidney along with the information for special renal imaging studies and what the imaging study would look like in certain diseases and why. I had information about normal bone growth along with the metabolic diseases of bone, I included calcium homeostasis (parathyroid stuff) in this section as well. For me, this system allowed me to synthesize the information without feeling like I was just trying to memorize data.

I’m a very visual learner so I made 3 large posters showing diagrams of how a radiograph is formed–from x-ray tube to film and all the steps in-between–I also did this for a fluoroscopic image formation. These 3 images had most of the basic physics info and was a great way to see the inter-relationships. I hung these posters near my study space and ended up looking at them daily. I have heard posting study sheets on the bathroom wall is helpful as well… one of my friend’s school-age kid can recite the scientific names of most common reptiles because of this! Every minute counts!

AZ:What are your top 3 tips for studying for the written exam?

Sandy:

1. Make a schedule and try to stick to it, planning out your goals for each day or week.
Try to stick to these deadlines. You can revise it as you go, but it’s more important to
cover everything at least once than it is to learn everything there is to know about a
specific topic. So keep up a pace of moving on to the next thing instead of getting
bogged down with MR physics or something like that.

2. When it starts getting really intense, like a few weeks beforehand, take scheduled
breaks. I would exercise late in the afternoon, when I was starting to lose focus at my
desk. Then I would cook a slightly elaborate dinner or watch TV for an hour. Following
this, I could focus for another hour or so before bed. And, it kind of gives you
something to look forward to, and a way to diffuse stress.

3. Most important: the forest. Don’t sweat the small stuff. By remaining focused on
the big picture, you will attain a good overall understanding of the basics, and will be
able to answer most of the questions or at least narrow the answer down. You can do this
by reading different references for the same topic, if it feels like a weak point for you.
Remember, it’s multiple choice, so the answer’s going to be there in front of you. You
don’t need to memorize the all the types of trees in the forest, you just need to know
enough about the forest as a whole to identify the answers that don’t make sense or the
ones that seem the most correct.

Lastly, something that everyone told me which I didn’t believe, and I don’t expect anyone
to believe me, is that as a resident you already know most of the stuff before studying.
Physics and RadBio require knowledge of the basic principles and thus some reading, but
just being a resident will allow most people to answer most questions. I still recommend
spending a few days on the anatomy and physiology objectives, but this is to review weak
points and solidify prior knowledge. The weak points are those things that you learned
once in vet school and haven’t really thought about as much since then, like the names of
the portal branches and the developmental stuff like types of vascular ring anomalies and
the mesonephric duct.

Mathieu:

1./ Follow the objectives and don’t go crazy into too many details.
2./ Focus on the recent literature.
3./ Don’t stress and don’t panic, it is not that bad!

Lisa:

1. Know how YOU study best, now is one of the few times being selfish is important ! (notes, images, group, highlighting, study space).

2. Start early to avoid becoming overwhelmed, find a way to consolidate important information in a reviewable format that you can review easily as the test draws near (Trust me–you don’t want to contemplate rereading Bushberg the week before the exam!)

3. Schedule time AWAY from the books–I knew my limit was 5 hours / day of studying, and my best study time was mid-morning and later evenings–by planning breaks and my usual activities around this, I found that the time I did study was much more productive and I didn’t get frustrated thinking studying was taking over my life.

Thanks to Mathieu, Sandy and Lisa for all their helpful advice! Feel free to add to the discussion by posting comments.

Written boards are a huge cause of stress to residents. They loom over you from the day you start your residency, somehow making you feel guilty for not studying every spare minute. The amount of material seems overwhelming, where should you start? What should you spend the most time on? I asked three of the successful candidates who passed writtens in May to comment their study plans. Mathieu Spriet from Penn, Sandy MacLeod from Davis, and a resident who preferred to stay anonymous (we’ll call her Lisa), shared their thoughts.

AZ: How many months ahead of the exam did you start preparing?

Mathieu:

3 years! Well that’s not really true but it is a little bit… The past 3 years have contributed in passing boards for sure. I truly started working specifically for the exam in October. (ie when I decided to stop the few research things I was working on and decided to spend at least a little bit of time studying everyday; it did not really happen every day but almost…)

Sandy:

About a year before the exam, I started reading some of the textbooks (Christensen, Hall) and old articles. The majority of my prep was in the 6 weeks before the exam.

Lisa:

I guess I should say up front that this was my 2nd try at the exam–the first time I passed 3/6 sections. As it was my second time around and I had a better idea of what types of questions to expect, I was able to make better use of my time and spread my studying out over the 10 months prior to the exam. I would come across a clinical case that related to an objective and make sure I followed up on the case and tried to find any recent literature pertaining to the clinical case (pathophysiology, imaging studies, etc.). We only get one month of clinics prior to the exam for “cram studying”.

AZ:What did you start with and how much time did you study per week?

Mathieu:

The plan was to review all the vet rad literature from 2000 to 2006 by systematically reading the journal (from top page to bottom page). I started with 2000, was planning on doing that on 3 months (oct-nov-dec), it did not work… I was not able to cover 2005 and 2006 during that period but luckily I had read most of these years already before when they were coming out. Studying time: most likely 1-2 hours a day, a bit more on weekend, so most likely 15 hours per week. January, February and March, I started to review anat and pathophysio following the objectives (but I did not get much done for different reasons…) Then the 6 weeks off before the exam (~ 10 hours studying /day)… I kept the last week for final review and I divided the first 5 weeks according to the objectives in the following way:

• Radiobiology 3 days
• Anatomy 5 days
• Physiology 7 days
• Special procedures 3 days
• Alternate imaging 12 days! (US 4d, NM 3d, CT 2d, MR 3d)
• Physics 3 days

Sandy:

About 1 year before the exam, no more than a few hours a week. About 3 months before, I stepped it up to about 5-10 hours a week. About 6 weeks before, 10 hours a week. 4 weeks before (with the advantage of 4 weeks off clinics) I was at about 40-50 hours a week. At this time I treated it like a job: I would wake up, study all day until about 3 or 4, go for a jog, and review the day for an hour or 2 after dinner.

Lisa:

I started by reviewing the objectives posted online and then attempting to find recent or review articles that answered/related to the objectives. My goal was to study an hour each night and then 3-4 hours each weekend day–this didn’t always work. It sounds childish, but I found it helpful to set a kitchen timer and stick to it–both for studying and taking a break ( say a 20 minute break for each hour of studying). The amount of information is overwhelming and it is easy to fall into a trap of frustration and then avoidance if you can’t see some sort of “end-point”–even if it is just to break away from the books and grab a coffee.

AZ:What was your approach to reviewing the literature? (which journals, which years, any software, etc).

Mathieu:

Vet Rad 2000-2006 with going back to some older vet rad papers or other journal if cited in the papers I was reading.

Sandy:

Throughout the residency, I collected copies of non-vet rad literature from 2000-present. This mostly included JAVMA, Equine Vet Journal, JVIM, with a few references (maybe 5-10 total each) from JAAHA, Vet Surg, Vet Path, AJVR, JSAP.

I created a free account on PubMed and developed a saved search for the words “Ultrasound, Scintigraphy, Radiography, CT, MR” in the titles of articles from these journals (post 2000), printed out this list (about 300 since 1999), and pulled the ones (maybe less than half) that looked good. The point is, if the title of the paper didn’t have an imaging modality word in it, it probably wasn’t as important.

I spent about 75% of my literature reading time on Vet Rad, though. Early on (a year before), I read the old Vet rads (from 1980 to 2000). I didn’t spend much time on an individual article unless it looked “testable,” for example, some of the early contrast study papers are applicable to special procedures, and some papers on radiography of ceratin diseases seemed important. However, early US and CT papers have limited value in todays clinic diue to changes in technology. If an article seems obsolete or irrelevant to your clinical experience, it probably is, and won’t be tested. Unless it’s a “classic” such as a special procedures paper, or a specific disease.

To review the post-2000 papers, I read them and underlined the points, then took notes of 2-3 major take-home points from the article. Real basic stuff. This process of distilling the articles down will start slow, but you’ll get really efficient at it after a few days. And this means you will remember at least 1 significant conclusion about each paper.

There are basically 6 categories which ended up as 6 piles of papers on my floor:

• Alternate Imaging: US, CT, MR, NucMed
• Radiography
• Special Procedures

Lisa:

I had tried using EndNote and organize articles by keywords, but it became more of a chore than a helpful study aid. My goal for the exam this year was to try to find a recent article that related to each individual or group of written objectives. I especially looked for review articles. I would then download the pdf file and use Adobe acrobat to capture the important images, tables or charts and then paste them to a separate document (I used Mac Word)–these pages were a great way to review as I also made additional notes on these pages throughout my studying.

The main journals I focused on were the last 5 -10 years of Vet Rad–plus “classic” technique articles.

• JSAP and InPractice: Great source for review articles (special procedures)
• JAVMA / JAAHA: What’s your Diagnosis and review articles, occasional imaging based article
• Journal of Veterinary Emergency and Critical Care: Some good physiology articles

Lisa sent a few sample pages of her study notes as an example. Download the PDF if you’d like to take a look (1.3 MB).

Sample study notes

I’ll post part II of the interviews later this week. Residents, this is your chance to share your experience. What was your approach? Leave a comment!

It’s time for another journal roundup this week. Not all of the articles are new, but if you are a resident and haven’t discovered the Radiographics physics reviews, here’s your chance. There are lots of other great ones in the archives of the journal. Let me know if there are other articles you think should be included, or post them yourself on CiteULike under group VetRadiology. You may need a subscription to view some of these articles. The last three issues of the Canadian Veterinary Journal are not available online.

Forterre F, Kaiser S, Matiasek K, et al. Adenocarcinoma Metastasis of the Intertransversarius Cervicis Muscle Eliciting a Right Forelimb Lameness in a Dog. J Vet Med A Physiol Pathol Clin Med 2007;54:250-253.

Du Plessis CJ, Keller N, Millward IR. Aberrant extradural spinal migration of Spirocerca lupi: four dogs. Journal of Small Animal Practice 2007;48:275-278.

Hayes AM, Gregory SP, Murphy S, et al. Solitary extramedullary plasmacytoma of the canine larynx. Journal of Small Animal Practice 2007;48:288-291.

Smith PM, Talbot CE, Jeffery ND. Findings on low-field cranial MR images in epileptic dogs that lack interictal neurological deficits. The Veterinary Journal 2007;In Press, Corrected Proof.

Scheck MG. Liver lobe torsion in a dog. Can Vet J 2007;48:423-425.

Boyd DJ, Miller CW, Etue SM, et al. Radiographic and functional evaluation of dogs at least 1 year after tibial plateau leveling osteotomy. Can Vet J 2007;48:392-396.

Zatelli A, D’Ippolito P, Fiore I, et al. Ultrasonographic evaluation of the size of the adrenal glands of 24 diseased cats without endocrinopathies. Vet Rec 2007;160:658-660.

Zhuo J, Gullapalli RP. AAPM/RSNA Physics Tutorial for Residents: MR Artifacts, Safety, and Quality Control. Radiographics 2006;26:275-297.

Pooley RA. AAPM/RSNA Physics Tutorial for Residents: Fundamental Physics of MR Imaging. Radiographics 2005;25:1087-1099.

Barrett JF, Keat N. Artifacts in CT: Recognition and Avoidance. Radiographics 2004;24:1679-1691.

Localizing the mass

If you see an obvious mass, the first step is to determine what quadrant of the abdomen it is in. Right cranial? Caudal midline? Mid-abdomen? When you narrow it down, you can make a mental list of the organs present in that area. For example, the right cranial quadrant contains liver, GI, and pancreas, and the right kidney and adrenal are in the retroperitoneal space in this area.

What other organs are dispaced and where?

The next thing to do is to see what organs are being displaced by this mass. You have a mental picture of where the organs should be, so check to see if any are out of place in that region. You have a right cranial quadrant mass, and notice that the duodenum is displaced laterally, and the pylorus is displaced medially, leaving a widened gastroduodenal angle. What lives between the duodenum and the pylorus? The pancreas. So a pancreatic mass would be your top differential.

Take a look at this radiograph. There is a mass located between the fundus of the stomach and the left kidney. The left kidney is displaced caudal to its normal position. The mass is located in the left cranial quadrant of the abdomen, in the area of the proximal extremity of the spleen. Organs normally present in the left cranial quadrant are stomach, left kidney, left adrenal, spleen, and pancreas. Which one could displace the left kidney caudally? A left adrenal mass tends to rotate the cranial pole of the kidney laterally, and the pancreas is a bit more ventrally located. Another vital clue: the normal stomach and kidney are visible, but a normal proximal extremity of the spleen is not. The spleen is most likely the cause of the mass.

Indistinct abdominal masses

Sometimes the mass itself is not clearly visible, and you just see the mass effect, or the organs displaced by the mass. It looks like an area of poor detail with increased soft tissue opacity, and you can see that organs are moved away from it. Just use the same technique to narrow down the organs that it could be originating from.

Generalized organ enlargement can cause the same signs

The same principles apply with generalized organ enlargement. Enlarged organs will displace other neighboring organs away from them, and this can help you to confirm that an organ is enlarged. Think of hepatomegaly changing the gastric axis.

Check for the silhouette of the normal organ

Finally, if you think it’s originating from a particular organ, check to see if you see that normal organ. If there is a mass in the distal extremity of the spleen, you will probably not see the normal triangle of spleen caudal to the liver.

Determining the origin of an abdominal mass:

*localize it to a quadrant of the abdomen

*determine what organs are in that quadrant

*look to see what organs are displaced (and where)

*check to see if you see the normal silhouette of that organ

*make your list of differential diagnoses

What Are The Different Types Of Diaphragmatic Hernias?

Here is another great question from the sophomore class about the different types of diapragmatic hernias.

Hiatal hernia

A Hiatal hernia happens when the cardia and fundus of the stomach pass cranially though the esophageal hiatus in the diaphragm. The herniated stomach is in the caudal mediastinum, and the lower esophageal sphincter is located cranial to it. Sometimes an esophagram can highlight the area of the lower esophageal sphincter, and outline rugal folds within the caudal mediastinum.

Paraesophageal hernia

A paraesophageal hernia occurs when the stomach herniates through the diaphragm beside the esophagus. This can happen inside or outside of the mediastinum. A contrast study is necessary to outline the position of the stomach.

True diaphragmatic hernia

A true diaphragmatic hernia is a congenital defect in the diaphragm that is still covered by the peritoneum. These are very rare, and tend to look like an abnormal bulge or asymmetry of the diaphragmatic contour.

Peritoneal pericardial diaphragmatic hernia

One more type of hernia that you will hear about is a peritoneal-pericardial diaphragmatic hernia, or PPDH for short. These are also congenital, and result from a failure of some of the parts of the diaphragm during development. This leaves an opening between the peritoneum and the pericardial sac in the mediastinum, and abdominal contents such as the liver, intestines, omentum etc. can become trapped there. On radiographs, the heart has the same globoid shape as a pericardial effusion, and you may be able to see gas in some bowel loops. This anomaly occurs most often in cats, and they may also have fewer sternebrae than usual (normally 8), or an abnormally shaped sternum, because of the same developmental defect.

Traumatic diaphragmatic rupture

A traumatic diaphragmatic hernia is more properly known as a diaphragmatic rupture. The opening between the peritoneal and pleural surfaces is not a congenital opening, but an actual tear in the muscle. This is the type we see most often after animals are hit by a car, or suffer other trauma. The contour of the diaphragm is not visible, or is interrupted, and there is increased soft tissue opacity (+/- recognizable abdominal organs) in the pleural space. Pleural effusion often goes along with this injury, and the abdomen can appear empty.

How to tell what kind of hernia you are looking at:

• Is it in the caudal mediastinum? If yes, think hiatal hernia or paraesophageal hernia.
• Is the lower esophageal sphincter cranial to the diaphragm? If yes, this is a hiatal hernia.
• Does it involve the pericardium and/or sterunum? If yes, this is a PPDH.
• Is the diaphragm not visible, and are there abdominal contents in the pleural space? If yes, it is a diaphragmatic rupture.
• Is there an abnormal bulge or contour of the diaphragm? This could be a true diaphragmatic hernia.

The radiology report

Each radiological study is a diagnostic test. The clinician has already examined the animal, and has a list of differential diagnoses in mind. The goal of the imaging procedure is to rule in disease, rule out disease, or discover new information.

The report on any diagnostic imaging study needs to be structured and concise. For any written or oral report, including the oral board exams, I like to break down the radiology report into four sections. A good description, a radiologic diagnosis, a ranked differential diagnosis, and further recommendations are what you need.

Description

The first part of your report should describe the radiologic findings. I like to use a systematic approach, working from the outside of the radiograph to the inside in. First evaluate technique and positioning, and how it could affect your interpretation. For example, if the radiograph is underexposed, that could explain a finding of poor peritoneal detail. Radiologic findings include classic Roentgen signs such as size, shape, opacity, number and position of organs. If you are evaluating the liver, you might say that the liver margin extends beyond the costal arch, and the margins are rounded. Describe your findings first, then move on to the next step.

Radiographic Diagnosis

The radiographic diagnosis is a summary of your findings. Radiographic diagnoses are specific terms that describe your observations in a concise and more concrete form. The radiographic diagnosis that we can make from the description of the liver changes is hepatomegaly. There may be more than one radiographic diagnosis on a set of images, and this summary helps you to gather them all together to consider the cause.

Differential Diagnosis

The next step is to make a prioritized list of differential diagnoses for your findings. If you have one main finding, list differentials that could be causes. Hepatomegaly could be caused by hyperadrenocorticism, diabetes, inflammation, toxicity and other causes. When you have more than one finding, like an abdominal mass and free peritoneal gas, try to make a story that ties both of them together, like a gastrointestinal mass with rupture and septic peritonitis. If one explanation doesn’t make sense, you can list differentials for both findings. It’s also helpful to list the most significant findings first, and incidental findings last.

Recommendations

Your list of differential diagnoses may be different than the original set that the clinician ordered the imaging study with. You may have come up with a confident diagnosis and obvious plan, such as surgery in the case of septic peritonitis. If there are several possible causes for the findings, suggest further imaging studies that could help to narrow the list. Ultrasound, cross-sectional imaging, and fine needle aspirates of lesions are all possibilities.

The concise report

Following these four steps will lead you to a concise, structured report to help you and the clinician determine what the next step is. It’s essential in clincial and academic practice, as well as for the oral board exams.

The four parts of a radiology report: