Got Rain? UCSF Medical Center

Speaking of prostates, I just returned from UCSF where I gave the Earl Miller Memorial lecture. Since there isn’t much I can teach the UCSF group about prostate MRI, I chose the topic, “How Radiologists can add Value to the Management of Patients with Crohn’s Disease”. This will also be my topic for the ESGAR meeting in Paris this year and will present an opportunity to highlight the efforts and achievements of the SAR disease focused panel on IBD to our colleagues in Europe.

Derek Sun, Michael Ohliger, Jane Wang, Ben Yeh, Antonio Westphalen, Ron Zagoria, John Mongan

There’s no place like California. The on-going drought ensured perfect weather for my visit (although I would have gladly suffered the rain to help out the farmers). The pre-visit checklist they sent me included the usual inquiries about my topics and disclosures in addition to a few nonstandard questions that you would only find on the West Coast: Will you be drinking white or red during your talk (I chose white)? Will you be wearing clothes (yes, but only because I don't have any ties that match my skin color)? How many wives will be accompanying you to dinner (oops, sorry, that was last month)? Unfortunately, drinking wine during my talk didn’t improve the quality of my delivery nearly as much as it improved my perception of it.

Lunch at UCSF was nothing like lunch at Indiana. No gigantic fried pork sandwiches for one thing. Instead, I had the free-range, gluten-free, organic squash soup in a fully recyclable bowl made by fair trade craftsman using eco-friendly, sustainable methods (I’m still not sure what a free-range squash is. At UT Southwestern, we have free-range residents). For dessert, I had a green tea enema. 

The views on campus are stunning, but the real show-stopper at UCSF is the faculty. Their friendly, relaxed demeanors belied the incredible depth and breadth of their expertise and range of accomplishments. I particularly enjoyed catching up with former SUR president and Wake Forest co-worker Ron Zagoria. Ron taught me much about GU radiology and nearly everything I know about leadership during the years we worked together at Wake. I also enjoyed some one-on-one time with Emily Webb, Dave Avrin, Ron Arenson, and Ben Yeh. I plan to tap into Ben’s extensive knowledge of spectral CT as we ramp up our program at UT Southwestern.

The view from the Library.

I also had the pleasure of all-to-brief encounters with many SAR members, including SAR president elect Judy Yee, prostate guru Antonio Westphalen, MRI prodigy Mike Ohliger, hyperpolarized Carbon-13 aficionado and former IEC participant Jane Wang, PET/MR advocate Spencer Behr, US disciples Tara Morgan and John Mongan, and heir to the Workshop throne, Stefanie Weinstein.

Judy Yee, Emily Webb, and Ron Zagoria get soused before my talk. Good move. 

The next time you visit San Francisco, consider making the two hour drive (30 minutes if you routinely drive in Dallas or LA) down to Point Lobos State Reserve. Few places in the world combine such spectacular scenic vistas and wildlife diversity so close to a major metropolitan area. While there, my family and I spied sea lions, harbor seals, sea otters, and even a few whales from the rocky cliffs overlooking Monterey bay. Volunteers set up spotting scopes at numerous locations throughout the park to provide visitors with close-up views of the animals. If you plan a trip, avoid the weekend. The park can absorb the crowds well enough, but the limited parking options forced us to park far from the entrance. 

One of many spectacular views along the coast at Point Lobos.

We capped the day off with a seafood dinner at Fisherman’s Wharf in Monterey, stalked the entire time by hungry seagulls. 

Looking for handouts. Can you find the bird that photo-bombed him?

Indiana University: Definitely not a fly-over program

No SAR visiting professorship would be complete without a visit to Indiana University. SAR member Dean Maglinte makes certain of that! Former VP Desiree Morgan dropped by for some talks last year, and they've been raving about it since. Because lecturing on the pancreas was part of her gig, she threw a pancreas party for the residents that stole the show- my show! How was I supposed to compete with a pancreas party? Dean had requested prostate MRI as my topic, and despite delivering what many would consider a seminal talk, every one there viewed Desiree with such vast deference that even my best joke (“Rectum? Damn near killed him!) couldn't get a rise out of the audience (at least the residents should be better prepared for their ABR digital exam now). While I’m sure there are some places in the world where a prostate party would be welcome, University of Indiana wasn’t one of them. Word of advice for next year’s Igor Laufer professor- everyone loves a party, so pick an organ that goes well with punch and cookies.

IU residents and fellows

My first night in Indianapolis, Dean Maglinte and SAR member Kumar Sandrasegaran treated me to dinner at St. Elmo steakhouse, where they are known for their fiery hot shrimp cocktail consisting mostly of fresh horseradish. Horseradish, a perennial plant of the Brassicaceae family, has been used for years as a medicinal for sinus disorders. I can vouch for its effectiveness, as well as its deliciousness, as St. Elmo’s fire effectively denuded the mucosal lining of my entire upper respiratory tract.

Not for the faint of sinus: The shrimp cocktail at St. Elmo's.

The IU Abdominal Imaging faculty impressed me with their academic productivity and teaching efforts despite RVUs in the upper quartile. I sensed that their deep commitment to the academic mission sustains them through these challenging times. For many of their scientific endeavors, they benefit from an impressive, fully integrated radiology/pathology database. They also integrate daily, organized teaching efforts into the workflow to ensure the best possible experience for their residents and fellows.

Kumar Sandrasegaran running a reading room conference for the residents.

My visit wasn’t all work and no play. My tour of the Methodist hospital campus was a thinly veiled attempt to justify my riding the “people mover”. This consists of an automated, elevated light rail train that runs a regular route above the streets of Indianapolis between hospitals (supposedly the only private line of its type to run over public streets). It lends a Disneyesque quality to the Medical Center, when it isn’t catching fire (which it did less than a month after opening). For more facts about IU's people mover, try the following: http://en.wikipedia.org/wiki/Indiana_University_Health_People_Mover

The IU people mover- more fun than Disneyland

I also witnessed first hand something more dangerous than a people mover fire (even if the lethal effect takes years to develop)- the pork tenderloin sandwich. The heart of this official state sandwich of Indiana (yes it really is the state sandwich) consists of an enormous breaded and fried slab of pork.

The state sandwich of Indiana. Yes, that's a normal-sized bun. 

My last night, I enjoyed a memorable dinner with members of the Radiology Department, including interim Chair Himanshu Shah and many colleagues from the SAR. As might be expected in the presence of such a diverse and talented group, the dinner conversation ranged from the origins of wine to the benefits of a clean colon. I try to learn something new from every place I visit, and that night I learned that Princess Diana regularly engaged in the practice of colonic cleansing (go ahead, google it). Having experienced a thorough colonic purge the last time I ate pizza at the Miami airport, I can’t say I’m a fan (although I did get an idea for a novel CT colonography prep involving iodine-labeled mozzarella). Whether it was the late hour or our raucous banter, the restaurant was thoroughly cleansed of diners by the time we left. 

SAR members at IU from the left: Marc Kohli, Dean Maglinte, Kumar Sandrasegaran, and John Lappas. It took the photographer so long to set up this shot that Kumar fell asleep.

Good thing it wasn’t a powder day: The University of Utah

SAR member Marta Heilbrun invited me out to the University of Utah as part of the Igor Laufer visiting professor program. While there, I gave talks on renal cell carcinoma, CT of abdominal pain, and MR angiography to their residents and fellows. Had it been a powder day, I would have been speaking to an empty room. You see, Salt Lake City is snow starved, and I suspect that the U. will empty out at the first signs of serious “pow” (that’s “powder” for you non-skiers). All you SAR members in Boston should box up some of that snow you’re hoarding and send it westward!

University of Utah faculty, body fellows, and residents: Nicole Winkler (faculty, SAR!), Oliver Edwards, RJ Willmore, Ben Romney (fellow), Reza Pakdaman, Maryam Rezvani (faculty), Marta Heilbrun (faculty, SAR!), Jakie Taylor (fellow)

This time last year, I lectured in SLC at a urology conference and planned to ski with Marta. Unlike this year, there had been some fresh snow fall. Marta blew me off with the oft-used Utah expression, “no friends on a powder day”. That’s OK; she redeemed herself this time by skiing blue rectangles with me (she’s more of a triple black diamond of death kind of skier). We were joined by her hubby Ron and SAR member (and 2014 RSNA Outstanding Educator Award winner!) Paula Woodward.

with SAR members Paula Woodward (left) and Marta Heilbrun. 

When I arrived in Salt Lake City, Paula met me at the airport and drove me straight downtown, where she gave me a very educational, walking history tour. We were fortunate to see the massive Salt Lake Tabernacle organ in action during our walk through the Temple grounds. The original organ, dating from 1867, has since undergone multiple modifications and modernizations and now contains 11,623 pipes.

If you are in the mood for food while visiting SLC, I would recommend the Copper Onion where Paula treated me to a feast that I won’t soon forget. Marta also hit a homerun with her choice of restaurants, “Bodega”. Easily one of the hippest eateries in SLC, the menu featured some pretty edgy dishes. Who would have thought that caramel corn would go with white cheddar cheese and duck fat? OK, maybe that one wasn’t exactly in synch, but the chicken was killer! Like most hipster hangouts, Bodega believes in ethical food. In fact the chicken we ate died of natural causes. According to the autopsy report, the chicken was enjoying a cold one while taking a shower and slipped (how many times have you heard that one?). Had it been something other than Pabst, it might have survived.

Why I never drink beer in the shower.

That chicken had amazing sphincter tone. It took three of us to get the can out.

Dinner companions Leif Jensen, Paula Woodward (SAR!), Loren Longenecker (resident and UT Southwestern grad!), Marta Heilbrun (SAR!).

Like the Brigham, Utah’s Huntsman Cancer Institute has an intraoperative MRI scanner. But the real show-stopper was the view from the Institute’s cafeteria. 

It's a little hard to see the mountains in this photo, but they're out there. 

After my last lecture, I met with Marta and a few of her colleagues to talk about some interesting work they are doing to attempt to determine the actual value ($$) that a radiology resident or fellow adds to a radiology department. The answer is likely to be very controversial and far from straight forward given the large number of confounding factors, but the question is an important one in this era of value-based health care. I am certain that this work will attract plenty of attention as programs struggle to determine the residency program size that maximizes return on investment. Pretty soon, we’ll all have price tags. In a few years, you’ll be able to find me on the bargain-priced table along with my textbooks.

The Univ. of Utah residents put forth a value-laden performance in my unknown case conference. I think it had something to do with the water.

Why all the Utah residents are so smart. 

The residents were also treated to the most amazing lunch spread I’ve seen at a noon conference. Check out the chocolate covered strawberries… really? Isn’t it enough that you live 20 minutes from some of the best skiing in the world? You should have to eat sand.

Chocolate covered strawberries at noon conference? Seriously?

All things considered, it was a great trip and I highly recommend SLC and the Univ. of Utah’s medical center as places to visit. My only suggestion for improvement when the next Igor Laufer professor visits is that they drive him/her around in something bigger than a mini cooper. 

Mini coopers have infinite head room. Fortunately, it was a nice day. 

Westward ho! Farewell Wake Forest, Howdy UT Southwestern.

I have started my new job as Vice Chair of Clinical Operations and member of the Abdominal Imaging division in the Radiology department at UT Southwestern in Dallas, Texas. Don’t send anything to my Wake Forest e-mail address, as I won’t get it. I’ll miss my many friends who served alongside me at Wake during the last 10 amazing years and can never repay them for their support and collegiality. In case you are thinking it, no, I wasn’t fired, no, UT wasn’t desperate (OK, maybe a little), and yes, my wife is OK with it…mostly.

UT Soutwestern's new teaching Hospital

From a different angle

The nearly completed Parkland Hospital

Speaking of my wife, my move would have been completely hopeless without her help. She is the most organized, capable person I know and thought of everything I would need to survive anything short of a zombie apocalypse during the next 6 months. The plan is for my family to join me in the summer, provided I still have a job and there hasn’t been a zombie apocalypse*.

Prior to getting hired at UT, I volunteered to take an on-line personality test (Winslow personality profile). I got near the lowest possible score on “Ambition” (disclaimer: this is actually true). This makes sense, because I had my cat answer some of the questions, as I was too busy working on the move. I later discovered that she was doing some covert background reading. When we moved the living room sofa, we found 7 fur mice, 3 catnip toys, 6 rubber bands, and a copy of the book the seven habits of highly effective nappers. 

Peaches the cat scored low on ambition on the Winslow Personality Profile

Dallas will be a completely different experience from Winston-Salem. As implied in a previous post, Dallas drivers are insane. Not the slow insane kind of drivers you find in a congested place like New York or Boston. These are high-speed maniacs who seem to be taking their cues from the makers of Grand Theft Auto. Fortunately, it’s Texas, so I can upgrade my shot gun to a missile launcher any time I want. In addition to oil and the Cowboys, Dallasites love valet parking. That probably explains all the crazy drivers out there and the occasional quantum jumps in my car’s odometer. On the plus side, if you survive the drive, there are endless options for dining and entertainment here.

Neil Rofsky (Chair) and SAR member Lori Watumull (Abdominal Interim Division Chief) were very accommodating of my Igor Laufer visiting professorship schedule. Of course, I wouldn’t have considered moving without being able to fulfill my pre-existing obligations; regardless, they saw the value in such a program to all involved, and were fully supportive from the beginning. For their support of this once-in-a-lifetime opportunity, I am most grateful. Here's a list of SAR members at UT Southwestern in no particular order. Be sure to say "Howdy" the next time you see one of them.

Drs. Gaurav Khatri, Ivan Pedrosa (just submitted application), Lakshmi Ananthakrishnan, Kristen Bishop, Travis Browning, Julie Champine, Edward Chen, David Fetzer, Jeff Pruitt, Lori Watumull, and Theresa Huang.

My new job will be challenging, but there is remarkable energy at UT Southwestern that promises to make it fun as well. Neil continues to recruit top talent from around the country, and I am beginning to feel a bit like a Neanderthal compared to the typical new hire (no offense to the 20% of people out there who have some Neanderthal DNA in their genome). Academic endeavors are encouraged and supported at UT Southwestern, so I expect to see lots more participation in the SAR from this exciting place. We are currently looking for a Division Chief of Abdominal Imaging who can mentor our bright enthusiastic young faculty, and I can’t imagine anyone better to do that than an active member of the SAR. For those of you in the northeast buried under > 6 feet of snow, consider never having to shovel snow or pay state income taxes again.

Texas also provides some excellent dark sky sites. Here are some photos I took recently about 3 hours outside of Dallas.

If you look closely, you can see the famous Horsehead nebula

Star trails over Fort Griffin, TX

*For information on how to survive a zombie apocalypse, see http://www.cdc.gov/phpr/documents/11_225700_A_Zombie_Final.pdf

Brrrrrrrrroston part 3: Boston University Medical Center

The last stop on my Boston tour was Boston University Medical Center. There, SAR member Jorge Soto and colleagues gave me a warm welcome despite the record low subzero temperatures outside. 

It was so cold that day, the public schools closed to prevent putting Boston’s youth into cryogenic stasis. 

Once defrosted, the BU residents proved to be formidable case-takers and gracious hosts. They also proved to be fun and interesting dinner companions and excellent judges of wine (one of the perks of being a BU chief resident is that you get to choose the wine at visiting professor dinners). I found the idea of having so many residents join in the faculty dinner refreshing. I also appreciated that they let me pass on the opportunity to spend the remainder of the evening touring some of Boston’s finest pubs out of pity. 

Andrew Tanenbaum, Milos Janicek, Jeffrey Gussenberg, Jorge Soto, Kira Melamud, Trevor Morrison, Robert Ruef

Before I left, Jorge graciously gave me a signed copy of the book he co-authored, Problem Solving in Emergency Radiology, a must read for any resident before taking call.

For those of you who don’t know him, Jorge is a gem of a person. He taught me that smart and nice are not mutually exclusive. When Jorge speaks, Chuck Norris listens.

In the end, even record cold temperatures couldn’t squelch the educational exchange that typifies a trip to Boston’s elite medical centers. My only regret is that I didn’t have sufficient time to squeeze in a visit to Beth Israel Deaconess (where SAR member Johnny Kruskal is Chair of Radiology). On the other hand, it doesn’t hurt to have a reason to go back- preferably in the summer! 

BTW, Johnny Kruskal only got the Chair at BID because Chuck Norris turned it down!

Brrrrrrrrroston part 2: Massachusetts General Hospital

After a brisk moonlit morning stroll in arctic conditions, I stopped at MGH where I gave a talk and resident conference, caught up on some personal work, and hung out with some more of abdominal imaging’s elite. I ran into SAR members Peter Hahn, Dushyant Sahani, Debra Gervais, Jim Brink (Chair), and Sheela Agarwal to name a few.

Some of the stellar Abdominal Imagers at MGH. Sheela Agarwal, Deb Gervais, Dushyant Sahani, and Peter Hahn 

It was fun and educational to see the Abdomen Division in action, particularly at their daily afternoon teaching and QA conference. For once I didn’t mind being the dumbest person in the room, as these guys were all so willing to share their knowledge. Dushyant spent some time enlightening me on dual energy CT applications in the abdomen (e.g. he loves it for pancreatic mass detection), and I hope to tap into his knowledge when UT Southwestern’s new multi-energy/spectal CT scanner gets approved for human use (coming soon). It was clear that not everyone at MGH was as excited as Dushyant about the added value of dual energy and that a healthy rivalry between the MR and CT camps existed. Fortunately, most disputes were settled by cordially agreeing to disagree and then keying each other’s cars after work. I just hope that the CT guys at MGH never find out about what the MR guys have been doing to their coffee when they’re not looking. I doubt they’ll find out from reading my blog. The impact factor is too low.

Depite the cold, it was a beautiful morning to walk to MGH

The MGH residents made short work of my unknown cases, which didn’t come as a surprise given the vast array of complex and interesting cases they see on a daily basis. I should have listened to them when I was warned that it wouldn't be a good idea to walk home given the plunging temperature and wind chill. Even Chuck Norris would've put on long pants for the two mile up-wind trek back to my hotel. Then again, Chuck Norris probably would've made the hotel come to him. 

Brrrrrrrrroston part 1: Brigham and Women’s Hospital

Members of the Abdominal Imaging Division at Brigham and Women’s Hospital, including SAR members Nisha Sainani, Ramin Khorasani, Director Stu Silverman, and Anik Sahni.

I just returned from a visit to Brigham and Women’s Hospital, Massachusetts General Hospital, and Boston University Medical Center, and once again, the weather gods had seen fit to punish me. It was cold (how cold was it, you ask?). It was so cold that Chuck Norris would have had to put on a t-shirt. On my walk to the Brigham from my hotel, I noticed I could no longer feel my extremities. I didn’t have a thermometer, but as a uroradiologist with a moderately full bladder I had no trouble coming up with a rough estimate of the outside temperature.

By measuring the time to freezing and factoring in my age and height, the estimated osmolality of urine, the half-life of alcohol in the body, and the wind chill, I came up with an approximate outside temperature of 18 degrees. 

In Boston, the number of uroradiologists per capita is fairly average, so such sights are relatively uncommon. In Ann Arbor Michigan, on the other hand, you really have to look where you step. By the way, it is a myth that urine can freeze before hitting the ground during micturition from standing height in any temperature extreme present on the surface of planet earth. However, it is not a myth that frostbite can result from testing this hypothesis, so better just take my word for it. If don’t want to take my word for it, you can consult the MythBusters episode on this topic in which they failed to freeze a simulated stream of urine at -70 degrees F. One last word of warning… MythBusters did show it was possible to suffer a mortal wound from a falling icicle, so be careful out there.

Fortunately, Brigham and Women’s radiology department was as warm as it was welcoming. SAR member and former President Stu Silverman and I had a great discussion about balancing career ambitions with expectations and life in general (bottom line: make your life/career what YOU want it to be, not what others want or expect it to be). I also got a tour of BWH’s amazingly integrated and accessible radiology IT systems from the equally amazing Ramin Khorasani, MD, MPH. The systems he helped implement make protocoling, patient scheduling, and accessing real-time productivity and quality metrics nearly effortless. Their ANCR system (Alert Notification of Critical Results) provides for painless documentation and closed loop communication of critical results with referrers. Anyone nterested in informatics should pay a visit to BWH and consult Dr. Khorasani’s many trend-setting papers on the topic. One word of caution… this high tech IT stuff is great as long as it remains focused on improving patient outcomes. Unfortunately, I suspect this will all end with the eventual enslavement of humanity (or at least the enslavement of radiologists).

I was able to catch up with SAR board member Bill Mayo-Smith on my visit. In case anyone was wondering where he disappeared to, he's returned to Boston!

I also had a chance to tour BWH’s 5700 sq ft AMIGO (Advanced Multimodality Image Guided Operating) suite. This environment integrates a fully functional operating suite with a 3T MR scanner and a PET/CT scanner. The 3T MR system moves into the operating suite on a ceiling mounted rail system, so there is no need to move the patient. At the time I visited, the PET/CT did not have a mobility solution, but I’m sure they are working on one. 

AMIGO 1: Ceiling mounted MRI scanner adjacent to the OR suite

AMIGO 2: OR with doors on either side leading to PET/CT and MR scanner

AMIGO 3: PET/CT on other side of OR