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

Planes, Trains, and Automobiles (Part 2): The NYU Morton A. Bosniak head to toe imaging conference.

SAR member Nicole Hindman presents me with a plaque at the NYU Head to Toe course that honors Dr. Mort Bosniak (right). 

After my brief stay in Boston, I boarded a train to Manhattan. I was lucky that the AV guy for Koenraad’s course was familiar with the trip and could give me some helpful advice. First of all, if you ever make this trip, take the Acela (express) train from the South Station. It makes the trip in little over 3 hours with very few stops, and the seats are the equivalent of first class on most domestic US flights (without those little hot moist towels that I never quite know what to do with). By boarding at South Station, you will have your pick of seats. The train has a “quiet car” (no loud conversations or cell phones) and a nice snack car. If you want to enjoy some coastal scenery, sit on the left side of the train (facing the direction of travel), although the sun can be an issue on this side early in the day. 

The Acela from Boston to New York

The NYU head-to-toe course was the first CME course I ever attended (back in 1988), and it is a fantastic course for general radiologists interested in a comprehensive multimodality, multispecialty imaging review. Now, over 20 years later, I was returning as the Bosniak lecturer, an honor made even more special by having Dr. Bosniak in attendance. Mort is an amazing guy, as sharp and accomplished as anyone you’ll ever meet. Of course, this could be said about any of the NYU abdominal imaging faculty, but few radiologists in the world can claim such a sustained impact on the field of medicine as Dr. Bosniak.

I always thought it would be cool to have a classification system named after me, but all the good diseases and organs were already taken by the time I started my career. The spleen was still up for grabs, but the best I could come up with for a classification of splenic lesions was L1 = cyst and L2= something else. My favorite classification schemes are the ones that have as many categories as there are reported cases (how do these get published?). Now, I am just content to classify nonmedical things, like Dallas drivers (L1 = crazy idiots and L2 = me). Why Dallas? See my next blog post!

Many people who don’t live in New York think of New Yorkers as loud and pushy. That’s probably because many of the people who do live in New York are loud and pushy. But it’s nothing personal. New York City is a loud and crowded place. Even the New Zealand rugby team couldn’t cross Times Square during the holiday season in less than 30 minutes. Even so, the people of New York have no problem waiting patiently for a good falafel.

No, this isn't the cab line at RSNA. These people are waiting for falafels.

The NYU group of abdominal imagers doesn’t have to be loud or pushy. Their contributions to our field speak for themselves. I was truly privileged to have spent an evening with such a talented group of imagers. It’s no secret that NYU consistently churns out some of the most influential leaders in abdominal imaging year after year. I asked former SAR president Alec Megibow how they do it. I think he said the secret is “good falafels”, but the restaurant was a little noisy, and I might not have heard him correctly. SAR members Alec, Nicole Hindman, Hersh Chandarana, Andrew Rosenkrantz, and Gen Bennett all gave outstanding talks during the abdominal part of the conference.

Dr. Bosniak tries to give me a big hug. Hersh (left) holds him back

Members of a truly extraordinary Abdominal Imaging section from left to right: Hersh Chandarana, Morton A. Bosniak, Nicole Hindman, Alec Megibow, Genevieve (Gen) Bennett, Andrew (Andy) Rosenkrantz, Krishna Shanbhogue. This picture was taken at Michael Jordan's Steakhouse in Grand Central Terminal. Michael Jordan couldn't be in this photo because someone had to take the picture. He was holding the camera between his knees.

Nicole Hindman and I had a nice discussion about unknown film panels over lunch. Be sure to cheer for her at this year’s SAR unknown film panel in Coronado. And here’s some more advice for her in case she needs it:

1) If you don’t know what something is, tell a joke.

2) If you don’t know what something is and can’t remember any jokes, pretend you are choking.

3) When the other team gets a case right, make a face like, “duh, the janitor* could get that one”.

4) When the other team gets a case wrong, make a face like, “have you thought of becoming a janitor*?”

5) If the janitor* looks like he/she might get the case before you do, quickly spill something.

6) When the panel is over, regardless of how you think you performed, immediately erase it from your memory. That’s what everyone one else in the room will be doing.

All in all, it was a great visit at a great time of year. No one decks the halls better than NYC! The only downer was the drive to the airport when it was time to go home (the automobile part of my journey). It should have been a 10 minute drive, but I think the driver was going too fast, as all the clocks at the airport showed that an hour and a half had elapsed at LaGuardia (Stephen Hawking would laugh at that one even if you didn’t).  It didn’t matter, though, because the flight was delayed while the flight crew battled their way to the airport through the impenetrable grid lock of New York’s rush (ha!) hour. 

No one does the holidays like NYC!

One of many imaginative holiday displays

A winter wonderland

*In reality, janitors are hardworking and intelligent members of a noble profession who are often unfairly and inaccurately depicted in jokes as ignorant, lazy, or unambitious by comedians who lack the inspiration and/or talent to create new/novel material. To see what janitors are really made of, read about the story of nursing home janitor Miguel Alvarez. 

Planes, Trains, and Automobiles (Part 1): Clinical MRI course sponsored by Harvard Medical School and Beth Israel Deaconess.

SAR member Koenraad Mortele (BID) runs a few excellent CME courses throughout the year held in Boston at the Marriott Long Wharf. I was fortunate to have spoken at the December Clinical MRI course on the topics of MRI artifacts and MR angiography. As a rule, I try to never turn down an invitation from Koenraad, as I know the experience will be as fun as it is educational. Never wanting to squander anyone’s money, I was able to find a one-way air fare to Boston from Charlotte for only $67! From there I took a train to NYC, but I’ll cover that trip in the next post.

The Harvard/BID MRI course director, Koenraad Mortele

On the fun side, I enjoyed night-time Boston all decked out in festive lights for the holidays and had an authentic Italian meal in the North End with Koenraad, Jorge Soto (BU), Steve Winn (see Maine Medical Center/Portland, ME post) and Koenraad’s current fellow and Steve’s former resident, Elena Resnick. 

Koenraad, Steve, me, and Jorge at Trattoria il panino in the North End

On the educational side, we learned that not everyone over the age of 35 knows what the word “detumescence” means. This point likely needs some clarification, only a little of which I can provide, as the wine at dinner was as good that evening as the food and the company. I’m not sure how we got on the topic, but I think there was a legitimate ultrasound imaging segue, and I do remember Steve (a former large animal veterinarian) telling us about how studs (of the horse variety) have to be restrained prior to performing their duties lest they overly enthusiastically engage the mare and suffer a penile fracture and subsequent detumescence. At some point in the discussion, Elena claimed that the word “detumescence” was actually an age discriminator and that she could tell with reasonable certainty if someone was over or under the age of 35 based on their familiarity with the term (i.e. people under the age of 35 don’t know what it means). 

Elena is the one next to Steve

Of course, we subsequently did what all good scientists would do… we put the hypothesis to the test by asking a random sample of subjects (couple at the next table) if they knew what the term meant. The null hypothesis was supported when they claimed to be both over the age of 35 (although they didn’t look it) and unfamiliar with the term. 

This nice couple was having a quiet dinner before we came along. They claimed to be over the age of 35 but were unfamiliar with the term "detumescence". This supported the null hypothesis (n=2, p > 0.05). 

None of us was willing to provide our subjects with the definition of detumescence, so they had to look it up on their smart phones. Not to be outdone, however, they countered by asking if we knew what the word “borborygmi” meant (while I admit that much of the material in these posts is completely fabricated, I can assure you this story was not). Fortunately, we had been SGR members, so this challenge was easily addressed.

We also learned at lunch that lobsters caught in the winter taste the same as lobsters caught in the summer (apparently, this question had been dogging Koenraad for some time, so he had been avoiding winter lobsters all these years). We were fortunate that one member of our group had done a presentation in school many years ago on lobsters and could give us an impromptu tutorial.

As expected, the MRI course was great, but an unexpected highlight was when a gentleman named Jeffrey Sprague came out during a coffee break and led the audience in rejuvenation exercises. 

The audience does rejuvenation exercises during a break. My dejuvenating lecture on MRA followed. 

Sadly, he got better course evaluations than I did. 

RSNA: The greatest show (and lines) on earth!

A popular photo op.

Love it or hate it, you can’t ignore RSNA. No other meeting on the planet, medical or otherwise, can boast that approximately 30% of its attendees purchased a winter jacket solely for the purpose of attending that one meeting. And for those of you who like to queue, RSNA is the place to be. Taxi lines, bus lines, Connie’s pizza and McDonalds lines, the options for endless queueing are… well… endless! My favorite is the bus line at the South building. That combination of toxic exhaust, freezing cold, and the nagging uncertainty of whether I am really standing in the correct line can only be experienced at RSNA. Believe it or not, there is an entire field of mathematics devoted to waiting in line (queueing theory). It’s been around since a Danish engineer named Agner Krarup Erlang published his first paper examining telephone networks in 1909 Copenhagen. Unfortunately, union rules have prohibited the use of queueing theory in the city of Chicago since 1910.

This looks like the line for the "3" bus, but it is really the line for the 1A bus!

The endless taxi line at the South Entrance. Here's a hint that I learned from a door man at the Hyatt. Walk across the street. If the mob dosen't kill you, you'll get a taxi in no time. 

For those of you who don’t like waiting in line, here’s a secret. It turns out that there is actually an underground black market at RSNA for badge ribbons. For the right price, you can get any ribbon you like, from Case of the Day winner to Board of Directors. Some of these ribbons will get you free food (like the RG reviewer ribbon), while others just get you street cred. Why pay $100 for a donor ribbon when you can get one under the table for $5 (unless, of course, you care where the money goes). Anyway, my point is that once you load up your badge with enough ribbons, no one’s going question you when you cut in line. Just pick a person to cut in front of with one or two ribbons who looks puny near the front of the line. Chances are good that they will want more ribbons and won’t want to risk alienating a powerful and influential member of the RSNA ruling elite. Be prepared to make small talk, because they will likely want to network with you. In the unlikely event that they have their priorities straight and don’t care about ribbons, make sure you can still take them in a fight.

If you don’t want to buy your ribbons, don’t lose hope. You can still earn them by toiling away on thankless committees for years while neglecting your family and pets. That’s how I got my paltry few. I’ll know that I’ve finally reached the pinnacle of my career when I have to lift my name badge to use the urinal. Did you ever meet someone at RSNA with wet ribbons on their badge? Well, now you know how that happens. I’m tall and not particularly ambitious, so I figure I’ll be good for a few more years. Some readers are probably unaware that in certain restrooms at McCormick place, there are actually attendants whose job it is to hold the ribbons for members of the Board of Directors while they relieve themselves. If you don’t believe me, just ask Reed Dunnick about it the next time you see him.

RSNA is always crawling with SAR members. Here are just a few at this year’s RSNA…

Marta Heilbrun (Utah), David DiSantis (Kentucky), David's lovely wife Denise, Steve Eberhardt (New Mexico), Me, Brian Allen (Wake Forest)

Cynthia Santillan and Cooky Menias

Drinking Caipirinhas with my evil twin Erick Remer (Cleveland Clinic).

David DiSantis spending quality time with Sadhna Verma (Cincinnati) and Shweta Bhatt (Rochester)

Power breakfast with Mark Lockhart (UAB), Desiree Morgan (UAB), Alec Megibow (NYU), Stu Silverman (Harvard), Eric Tamm (MD Anderson) and Evan Siegelman (Penn). Someone get Evan to join the SAR!!!