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Finding my niche: Diagnostic Radiology

Author’s note: I often have been asked by medical students why I chose diagnostic radiology. The piece that follows answers this question. This editorial is part of what I hope will become a series in the Bulletin. I encourage the members of ACMS to tell their own stories of how or why they chose their medical specialties or type of practice.

My professional career did not begin in medicine. Both my father and my Uncle Dave were pharmacists, having graduated from the Albany College of Pharmacy (ACP, now Albany College of Pharmacy and Health Sciences), in Albany, N.Y. I worked in their pharmacy on weekends and in the summers and, naturally, I was exposed to the profession. As a freshman in high school, I told my guidance counselor that I wanted to be an engineer. However, mathematics was never my forte, and I really enjoyed the biological sciences. And so, I decided to follow in the family footsteps and become a pharmacist, enrolling in what would be the last four-year class at ACP. (Ironically my father was in the last three-year class and my uncle was in the first four-year class.) During the summer of my senior year, Uncle Dave took me aside and said, “You know, you have too much talent to spend the rest of your life in a retail pharmacy. You ought to think of going to medical school.” Uncle Dave was like a second father to me, and he always gave me cogent advice. He also had mentioned this to my parents, who promoted the idea. My mother, of course, always wanted to brag about “My son the doctor.” I took the MCAT, applied to four medical schools and was accepted at two. I decided to attend SUNY Buffalo (now the Jacobs School of Medicine of The University at Buffalo). And so began my journey.

When I entered medical school in 1963, my original intent was to be a general practitioner, like most of the physicians whose prescriptions we filled for their patients. I had not given much thought to any of the other medical specialties. Buffalo, at the time, had a curriculum that emphasized clinical care over research. There was considerable clinical correlation with most of the basic science courses. Medical students are influenced by many factors that impact their ultimate career choices. They may have wanted to emulate a respected physician they knew in their early years, or a parent, or a faculty member. My younger son, Scott, was exposed to diagnostic radiology and to imaging of spine trauma at home and said, at an early age, that he wanted to be a radiologist like his father. However, once he entered medical school, he fell in love with orthopedic surgery and today is an orthopedic spine surgeon (and full professor) at WVU.

I became enamored of neurology during my freshman neuroanatomy course. As a boy, I had secretly wanted to become a detective, especially after reading Sherlock Holmes stories. Our clinical correlation in neuroanatomy came in a set of weekly exercises called “Find My Lesion.” We learned that by knowing our neuroanatomy and analyzing the patient’s symptoms and physical findings, we could pinpoint exactly where his/her lesion was located. I subsequently took several electives in neurology and did summer fellowships in that specialty after my sophomore and junior years. The first fellowship was purely clinical with Buffalo neurologist/neuropathologist Walter Olszewski. The second fellowship exposed me to the world of radiology. My project involved comparing radionuclide brain scans with cerebral angiograms, pneumoencephalograms and surgical and/or autopsy results. In the 1960s, radionuclide brain scanning using mercury (197Hg) was the only direct technique available for imaging of the brain. Angiography and pneumoencephalography indirectly showed the effects of intracerebral pathology on the cerebral blood vessels and ventricles respectively. (CT and MRI replaced these modalities.)

Once I started the fellowship, I realized that there were a limited number of scans and other neurologic imaging studies for me to review. And so, in the morning, I accompanied the radiologists while they did fluoroscopy and went over X-ray studies with the different medical and surgical teams. One morning while I was observing Dr. George Alker attempt a barium enema on an elderly patient, I had my epiphany. Dr. Alker tried to perform the study twice, and each time, the patient evacuated on the fluoroscopy table. While the technologists cleaned up the patient, we went into another room to do an upper GI exam. Dr. Alker explained to me before we returned to attempt the enema that radiologists only did things in threes. If we were unsuccessful after three attempts, the study would be cancelled. Sure enough, after the third attempt produced the same result, Dr. Alker said to the patient, “You win madame. The study is cancelled.”

As we left the room, he turned to me and said, “You know, doctor, that’s the beauty of this specialty. You can walk away from a situation like this, and somebody else gets to clean up the mess!” I thought to myself, “This I like.” More importantly, however, I also began to appreciate that radiology touched all aspects and all specialties of medicine.

Furthermore, I realized that radiology was very much like detective work in that the X-ray (now imaging) study represented the patient at that precise point in time and that by carefully analyzing the changes present, one could work backwards to identify whatever caused those changes. I had found my niche. Two years in the U.S. Air Force practicing as a General Medical Officer (GMO) reinforced my belief that I had made the right decision – a decision I never regretted.

As I look back over my decision, I realize that there were many indicators along the way that suggested that diagnostic radiology was to be my career choice. I was always good at doing jigsaw puzzles: picking the right shaped pieces, matching the colors and putting them in the right place. When I was in third grade, the teacher of my beginning Hebrew class would write a word on the blackboard. That word appeared only once on the page of the book spread out in front of me, and I was always the first one to find it. I had what we radiologists call the “eye.” And years later, in medical school, I loved my anatomy and pathology courses, particularly the lab work.

While in the Air Force, the GMO’s were responsible for covering the emergency department. The result was that I obtained considerable experience in that area. During my first year of radiology residency, I “moonlighted” in a local emergency room. In 1976, the American Board of Emergency Medicine was formed, and they invited physicians who had considerable experience in emergency medicine to take their exam, in addition to those who had completed a residency. I politely declined.

Once I started my residency in 1970, I had some additional choices to make. There were three pathways offered: General Radiology (two years of diagnosis and one of radiation therapy), Diagnostic Radiology (three years) and Radiation Therapy (now Radiation Oncology, also three years). One of the radiologists at my Air Force hospital told me that by training in the General Radiology program I would have more doors open when it came time to look for a job. I opted for Diagnostic Radiology since I had no interest in doing therapy.

We often are influenced by our mentors while we are training. My first radiology rotation was with Dr. John Gehweiler in the general reading room, where we interpreted chest X-rays and bone X-rays. John had a keen interest in anatomy and was a co-author of “The Anatomical Basis of Medical Practice.”1 He also was the “bone expert” at Duke and was recognized nationally for his expertise in spine injuries.2 With my experience in emergency medicine, I gravitated toward Dr. Gehweiler and became interested in bone abnormalities as well as in imaging of spine trauma.3

The other thing I discovered was that I loved teaching. During my residency, I had ample opportunity to teach medical students, X-ray technologists, as well as fellow residents in radiology and other specialties. This led to a career in academic medicine with stops at the University of Louisville, Duke and Allegheny General, where I spent 31 years.

What was my “aha moment?” I have often said that there are three Golden Moments in medicine: making the correct diagnosis; instituting the proper treatment; and seeing the patient recover. Diagnostic Radiology lives in the first of these. While I’d been certain I made the right choice for my medical career, it was reinforced one night during my residency. I was on call and had to perform an aortic angiogram at 3 a.m. on a patient who was suspected of having a leak from a recently placed aortic graft for an aneurysm. The study went flawlessly, and the first injection confirmed the diagnosis of a leak at the anastomosis site. An hour and a half after I left home, I crawled back into bed and my wife asked how it went. I told her the results and then said, “You know, that’s the beauty of this specialty. I significantly contributed to that patient’s care. And now I’m back home. I hate to think of those poor surgeons who will be up the rest of the night, not to mention the post-operative care they will have to give”

I had found my niche, and as I mentioned above, I have never regretted my decision. That’s my story. Tell us about yours.

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