RestaurantHey Reddit, I Am A Taco Bell employee who works graveyard shifts in a state where marijuana is legal. Ask Me Anything!
Nov 22nd 2016 by TeddyHansen • 35 Questions • 4802 Points
Hello, I am Dr. Justin McWilliams, an interventional radiologist at UCLA (https://www.uclahealth.org/justin-pryce-mcwilliams)!
I specialize in using medical imaging (x-ray, CT, etc.) to treat your medical issues in a minimally invasive way, often helping patients avoid major surgery.
Working through a tiny incision, we can do some amazingly powerful things: open clogged vessels, eradicate cancer with ice probes, control life-threatening bleeding, shrink enlarged prostates, ablate varicose veins to make your legs look and feel great, and kill tumors with chemotherapy delivered directly to their blood supply. And that is just a small sample of what we do! More info here: http://www.sirweb.org/patients/
I divide my time between treating patients and performing medical research. Ask me anything about interventional radiology, cancer treatment, minimally invasive solutions to your medical problems, the world of academic medical research, exciting new technologies in medicine, or anything else!
Edit: Hey all, I have to go to angio club (this is like a little club where dorky IR doctors show each other cool cases and drink cheap wine). This was really fun, have never done it before. Planning to come back to answer more questions tomorrow morning at 11 am EST. Feel free to share on your social media so we can generate more fun questions. Thanks everyone! -Justin
Edit #2: Will have to go at 1 pm EST- I am giving a lecture on HHT and liver AVMs at 1030 here in California, and my chairman will be there, so I better be on time. Thanks!
Edit #3: Have to go, but I'll be back when I have time, since I am a little OCD and can't leave questions unanswered, it will haunt me. Special thanks to UCLA resident physician Kevin Seals (https://twitter.com/kevinsealsmd) for telling me about Reddit and helping put this together. Reaching out to Kevin on Twitter is probably the best way to get ahold of me if needed. Cheers everyone!
What was the weirdest order you've gotten from people who are obviously stoned beyond belief?
Why is it that hospitals can have incredible hardware like electron microscopes, yet pagers are still being used?
Judas Priest, man. We get some weird shit at 2 in the morning. Off the top of my head, here are a couple:
•Guy who keeps mistaking us for KFC (our building is about 60 feet away from one) and argues with us when we tell him he's in the wrong drive thru
•Guy last week who thought happy hour was 2am, not 2pm (again, he argued)
•Woman who ordered 4 XXL Grilled Stuft Burritos and paid for them in nickels and dimes, a whole fucking ziploc of them. She started crying halfway through her order. Not sure what the fuck was going on there, but I felt bad for her.
Surprisingly (or maybe not), stoned people make really good customers. They're mellow a lot of the time, and they become regulars more often than not.
Good question! I wonder this myself when I'm walking around the grocery store looking like a drug dealer. I think it is because we need a cheap device that doesn't lose contact in hospital basements and other locations lacking cell service. Sat phones are too expensive to give us, I guess. I do have all my pages go to my cell phone as well, though, so I don't have to carry that thing everywhere I go...
I once asked for no sour cream. The guy read back "extra sour cream?"
Are you concerned about the long term effects of radiation exposure from fluoroscopy?
In his defense, our drive thru speakers are shitty as balls
I stand next to an X-ray beam almost every working day, so I am definitely concerned. Not so much about becoming sterile or anything, since that takes really high doses, but about small incremental risks of cancer, particularly leukemia or lymphoma. I'm hoping that instead, I will develop cool mutant powers like Spider Man, but I am told that is really really unlikely.
I wear a lead kilt and lead vest that make me look like a really slow Scottish warrior, and it protects from about 90% of the scatter radiation that I experience. I also wear a radiation badge that gets turned in every month, and radiation safety officers write me scary sounding emails about how many milliGray I was exposed to, but never really equate that to how much risk I'm exposed to. Fortunately I've done my own research, and it seems that the cancer risk from my occupational radiation exposure is fairly small in the grand scheme (cancer risk for the general population is 40%, but for me might be 40.5% or 41% after a lifetime of working in IR).
Interesting is that there are reports out there of cardiologists having tumors grow on the left side of their brain or face - this is more common because cardiologists typically stand with the radiation beam on their left side (same as me). I typically protect against this by hiring fat fellows (block a lot of X-rays) and standing behind them as much as possible.
What is the most difficult procedure you have ever performed?
This same fucking guy comes in once a week asking for 2 taco 12 packs with all soft tacos with no beef, no lettuce, no cheese. He shows up at midnight and pays almost 30 bucks for a bag of 24 tortillas. Hell if I know.
Wow tough question. One was a TIPS (which is basically a shunt placed through the liver under semi-blind X-ray guidance, used to relieve pressure in the portal system in patients with cirrhosis) that I was doing in a patient who was actively vomiting blood, bucking around on the table and generally trying to die. Another was a patient with a massive pulmonary pulmonary embolism who was 500 pounds and I was trying to navigate a catheter through the lung arteries to suck out the clot as their blood pressure was tanking and they were coughing blood and I had to decide whether to keep trying or call the surgeons to crack her chest. Both turned out OK, the TIPS patient survived and got a liver transplant a few days later, and the PE patient I was able to suck out enough clot to get them out of the woods, and the next day she was sitting up in the ICU eating french toast. Win.
Is this Matt's brother who works graveyard at the Taco Bell on Beaverton-Hillsdale?
Current med student who is very interested in a carrier in IR. What would you say would make a strong application for someone who is applying to an IR residency? Any suggestions about creating a strong application would be greatly appreciated.
Definitely start by not having any mis-spellings in your application or personal statement.
A strong application is the combination of a few things:
1) Good med school transcripts. Try to get some letters of distinction, or honors, or whatever your school offers. Work hard and be the first one there and last one to leave. It will be noticed.
2) High board scores. Especially step 1. It sucks to study for it but it is well worth it. A high score here can carry you a long way.
3) Good letters of recommendation. These get more important the farther along in training you get. If you are working hard and studying hard, and you aren't a total a-hole, then this should work itself out.
4) Research experience. Especially for academic institutions, they want to see one or more projects that you have carried through to the end. First author on a paper, or at least on a poster or conference presentation.
5) A really beautiful head-shot. Just kidding. Kind of.
Notice I didn't include a great personal statement. These all read basically the same to me, so I just skim them, looking for any signs that you are a mass murderer or serial rapist. Otherwise they don't make much difference, at least to me.
Hi Dr. McWilliams, just wanted to jump on with a very related question. I'm a current radiology resident planning to apply into IR prior to the switch in 2020, and I'm having a hard time gauging my competitiveness and how many programs/where to apply, since the more "objective" standards including grades and board scores are not as relevant to a fellowship application. I've heard great letters of recommendation and research become even more important (especially prior to the interview invitation), but wouldn't everyone have great letters and at least some research? How do you differentiate between candidates at that phase?
I guess from a practical standpoint that what I'm asking is, is there any way to gauge how competitive I am in order to figure out how broadly I should apply?
It takes some introspection. Look at the following things in yourself:
-How good is my board score? Yes we still look at that!
-Did I get AOA or lots of good grades in med school? We still look at that too!
-Is my radiology residency considered "top-tier"? That definitely helps your cause.
-Have I won any sort of awards or honors during residency?
-Did I do a lot of research, more than my peers?
-Has your own IR program told you you would be a shoo-in at their program?
If you have a lot of yeses to the questions above, you probably are sitting pretty, and applying to a dozen or so programs will do. If not, apply widely, since you can always turn down interviews after you are granted them.
Is it difficult to light up and smoke on the line, since Taco Bells have no exhaust hoods?
During residency, be nice to nurses. You never know who they have the ear of.
This is 1000% true. Not just during residency, either. Nurses can make your life easy or very, very hard.
How do you think the appointment of Jeff Sessions as AG will affect Taco Bell's revenue?
Can you speak to the turf wars between IR and vascular surgery? Do radiologists make better interventionalists because of the dedicated rads experience?
When the rubber meets the road, customers just want their food and they want it made right and quick. They don't give 3 fucks about the corporate suits or political parties. They just want a taco. The Steakhouse Burrito and Nachos are a pretty big success so far, and that should definitely help any dip in sales for this quarter. That's my observation. I don't know a whole lot about it though.
Oh, I get it. Taco. Trump. Joke. Wall. Immigration.
(Insert canned Big Bang Theory Laughter)
It's a pretty open war in many ways- we pioneered the procedures, but they adopted them and have gotten quite good at them in many cases. I do still believe that the imaging skills are what separate us from the other doctors who try to do our procedures. There is a power in my ability to have a patient come in, interpret their MRI scan, treat them, and interpret their imaging results, allowing me to determine what the best follow-up treatments will be.
TL;DR - yes, we are way better.
No she works in finance. I had dated doctors in the past, but sometimes it's nice to leave work at work and not "talk shop" all the time. I don't talk too much about my procedures and she doesn't tell me too much about her Excel spreadsheets, and instead we cuddle on the couch and watch Westworld
I think I have been showered with every bodily fluid at some point, which has prompted me to come up with a definite ranking of bodily fluids, in terms of which ones I don't want splattered on me... in order from most to least disgusting: -Feces -Vomit -Saliva -Urine -Ascites -Blood
At this point I'd say the last 3 don't bother me at all. Urine for example is sterile and really is just filtered blood, so it doesn't seem disgusting to me at all any more.
But I digress. I did have a patient who was having heavy GI bleeding from the stomach. When that happens, the blood passes through the digestive tract and gets semi-digested into a nasty semi-solid blood/feces cocktail called "melena". The patient came down for me to stop the bleeding, and proceeded to "melena" all over my shoes as I was helping transfer the patient to the table... and I wasn't wearing shoe covers. This prompted a stat trip to Sports Authority for new sneakers.
Funniest case- I had a patient come in for treatment of varicocele, which is like a "bag of worms" in the scrotum composed of blood vessels due to incompetent venous valves in the abdomen. Usually patients come for treatment because the varicocele hurts, or is causing a decrease in sperm counts... but he wanted it treated because he didn't like how it looked on camera. Turned out he was a male porn star. I happily treated him (but never looked for my handiwork on the internet)
Have you ever had fluoro stop working midway through a procedure? What do you do in that situation?
Yea, a few times. Usually a re-boot gets it going again, just like my PC and iPhone. If it doesn't, I wish I could say I get out a scalpel and just dive in there the old-fashioned way, but in reality we just move the patient to another fluoro suite (we have 4 IR suites here at RRH).
Med Rad tech here.
I've heard chatter about changes that would allow nurses to order, perform and report their own imaging work. What do you feel of this suggestion? I myself am very concerned about this as I completed years of schooling in order to take appropriate diagnostic images while you've undergone even further education to ensure those images are appropriately interpreted. I don't feel these jobs could be accurately done by an RN.
While it's probably less of a concern with high level IR procedures, what do you think about the possibility of rads and their image reading being replaced with computers? We already see this being done on a limited scale in mammography with CAD being used as a "second read", but it hasn't seen much penetration beyond that.
Beyond poor quality imaging (low quality images, sloppy pos'n), what is something that drives you nuts about us imaging techs?
Least favourite type of case to do/read? I've heard many complaints about the GI tract (swallows and enemas) from my doctors here. And then bitching about bone age studies.
I haven't heard this change myself, but I agree that it is a bad idea. There is a reason why we have to spend 14 years in training- there really is a lot to learn
Regarding CAD, this is definitely already here in some areas (like mammo), and for the rest of radiology, it is coming. I think it is a matter of time before you do a scan, and a computer auto-compares that to a library of millions of normal and abnormal scans, using pattern recognition. Then it spits out a report. Probably will still have a radiologist to double check it, but someday the humans will be the quality control rather than the other way around.
We have amazing techs at UCLA IR. The best thing a tech can do is anticipate what the doctor might want next. Sometimes you know the equipment so well you can suggest what tool might be right for the job. That's the sign of a great tech... along with staying in/near the room within shouting distance.
Least favorite case is definitely the dialysis graft de-clot. You spend an hour hugging the X-ray beam trying to pull and remove clot out of the graft, and when you finally do the angio run at the end to check your work, it is already clotted again. So discouraging sometimes.
Hi Dr. McWilliams, with new applicants being corralled into the esir or integrated pathways and the vir fellowship disappearing what are your tips for evaluating all the new programs as an interviewee?
Tough time to be an applicant, since IR is a popular field right now- I think we had 220 applicants for our 3 integrated IR spots. But just realize you will be able to get into IR even if you "only" match diagnostic radiology. So look for DR programs that have a strong associated IR program (and offer ESIR) and also apply to integrated IR programs, which would be even better. As far as evaluating programs, it helps to talk to the current or past fellows, they will be brutally honest- or come shadow in the department or do away rotations to see for yourself. There are lots of good programs but you have to find one where you feel like you fit in. For example I thought of going to Miami Vascular for fellowship (which is an amazing place) but I was single at the time and the thought of being in beautiful South Beach and never doing anything fun because I was spending 18 hours a day at the hospital just crushed my soul too much. So I stayed at UCLA and never regretted it.
PGY-1 here who's been accepted into a DR program with ESIR. I'm concerned that software will soon enable computers to interpret imaging in the near future, reducing the need for DR physicians, perhaps relegating them to just double-checking the computer's work. Is my fear justified?
Yea see above- it's a ways off though. In the same way, wouldn't you have some concern that an inpatient medicine doctor could be replaced by a robot that takes in all the lab values, vitals, X-ray reports, and synthesizes a diagnosis and best treatment based on its internal library of best practice literature? I've seen Terminator 2. I know what's going to happen. But overall I think robots are going to help us rather than replace us, at least for a long while.
What's one thing you wish nurses knew regarding recovery of IR patients?
Call my fellow before you call me. Especially if it's after 9 pm.
BioMed engineering grad student. Just learned about CT and MRI this week, truly fascinating stuff. What future do you see for medical imaging in the world of big data? I would imagine that using a person's genetics, medical history, and scans of other patients with similar backgrounds could paint a better picture for treating various problems. How has big data affected your field?
Also I'm a USC alum. I hope you're prepared to get your butt kicked this weekend.
Always ready for UCLA to lose. I gave up on expecting wins a long time ago. UCLA's MO is to beat lots of cupcake teams early in the season, just to get your hopes up, then crush your dreams with a string of late-season losses. So yes, I'm well prepared.
Glad you brought up big data. This is going to be absolutely huge in healthcare in general and in IR/radiology in particular. We capture a massive amount of data, but right now it is not meaningfully synthesized and summarized in a useful way. There are efforts underway to use standardized reporting (I run a SIR committee for this) so that all IR reports contain the same information in the same place- this would allow auto-exporting of data into huge registries. Once that can be combined with auto-pulling of outcomes data from the electronic medical record, we will be able to answer questions like "which treatment is better" or "what is the likelihood of this outcome" with great confidence due to the massive sample size.
This is just one example. Another would be the rad/path report, which is also being pioneered at UCLA. Why have the radiology report separate from the pathology report? They both are trying to establish the right diagnosis, and each has strengths and weaknesses, so the best approach would be to meld the two reports into a unified report that has the best accuracy in establishing diagnosis.
1) As a radiologist, what up and coming imaging technologies are you most excited about? I hear a lot about optogenetics making huge headway in the field of neuroscience, do you see something similar for hepatology?
2) With so much new research and publications printed daily and worldwide, how do you and your fellow radiologists keep up to date to give your patients the best care?
1) HIFU is one of the really cool new technologies- basically an ultrasound beam can be concentrated on a target, and the ultrasound energy causes vibration of the tissue resulting in heating. The targeted tissue can be heated enough to cause cell death. The whole thing can be done under direct MRI guidance and completely noninvasively- there are no needles needed. It is just starting to be used for prostate cancer, uterine fibroids, and soon will start seeing more use for liver and breast cancer, I think.
2) That's tough- there are way too many scientific journals out there. I go to a lot of conferences, where half the time I am playing words with friends on my phone, but the other half of the time I am listening to world experts summarize all the latest knowledge. Or sometimes I'm the one up there giving the presentation, which severely limits the amount of words with friends I can play simultaneously.
Thanks for being so generous with your time!
- What's your favorite kind of procedure to do? What was the most rewarding time you did that? When did you first do it?
- What's your least favorite part of your job? What gets in the way of your being productive? What could make those things better?
- What kind of follow up do you do on patient outcomes? Do you get any feedback as to how well both a given procedure is working and how well you/your team are doing them?
- How do you decide which procedures you'll do vs. the fellow vs. the resident?
- What's the nicest thing a patient has done to thank you? What about someone you trained?
- What's your favorite paper you've authored? What's your favorite paper you've read?
I really love treating liver cancer. Most people are given the diagnosis as a death sentence, because most of them have cirrhosis and would go into liver failure if they underwent a curative surgical resection. So they get referred to me with little hope. Sometimes, the cancer is too advanced, and there is little I can do- but in most cases, I can stop or even cure the cancer using minimally invasive techniques. I also love the liver cancer population, they often have a history of harmful behaviors like alcohol or drug use, have reformed themselves, and are really appreciative that a doctor wants to help them. Just a great feeling to go into clinic after the procedure and tell the patient their tumor is cured. I will never get tired of that.
Meetings. I have so many meetings, where precious little usually gets done. I try to follow the 4 hour work-week advice: avoid all meetings, and if you have to go, show up 15 minutes late and leave 15 minutes early. That way all the small talk is already out of the way, you can get something out of it and get out of there before you waste your entire day looking at some admin's Powerpoint.
We do. A lot of our research consists of retrospective studies where we review patient outcomes and use that in reverse to figure out how we should best do procedures and who we should best do them on. It's a big part of what I do, and thankfully I have lots of good medical students and residents who are keen to jump through all the IRB hoops and spend lots of hours sifting through patient charts to collect this.
I'm always supervising, but I try to let the trainee do as much as they safely can. Exceptions would be really critically dying patients, really high-risk procedures, and the occasional time when I get bored watching and decide I just want to "show them how it's done". IR really is fun, but kind of like video games, it is more fun to play than to watch.
I had an absolutely adorable elderly patient who had kept a medical text from the 1800s- it had belonged to her grandmother. It was called "The Cottage Physician" and it had awesome chapters on how to make salves and ointments and potions for any ailment (this was well before antibiotics and the like). I had been treating her for cancer for a few years, and one clinic visit she brought it down and gave it to me. I took it to a professional book restorer who re-did the cover and it now sits on my shelf in my office at home. Gives me a smile every time I look at.
I can't say any of my papers have been New England Journal-worthy. I'm more of a clinician than a researcher, so although I do have a number of publications, I'm not going to say any were world-changers. Favorite paper I've read? There was a terrific paper on how to correlate hepatic arterial anatomy with angiograms, that I think about every time I do a chemoembolization procedure. Totally nerding out right now.
Schwannomas in difficult places like tied up in the cauda equina or under the sciatic nerve under the buttock/ back upper leg. Would these treatments you mention apply?
Not sure- I don't do nerve or CNS work- we have a whole department of Neurointerventional Radiology here at UCLA. I should have them do a Reddit!
Hi Dr. McWilliams. Care extender at Ronald Reagan MC here! There's a chance I might have seen you around. Thanks for taking the time to do this AMA.
I am currently in year 3 of undergrad planning to apply to med school the upcoming cycle. I got interested in IR ever since my grandfather's cancer metastasized to his liver, and he underwent TACE treatment. Could you explain the TACE procedure, and maybe why TACE would be better than other approaches in certain scenarios for treating liver cancer? Since my grandfather only stayed one night post-op, I am assuming that TACE's upsides are that its highly localized and minimally demanding on the patient. Other than that, my understanding of the hows and whys behind TACE is pretty limited.
Also could you expand on the differences between IR and vascular surgery? (interest in both!) Are there instances where IR docs will work closely with vascular surgeons, or do the two specialties tend to operate autonomously? They seem similar in certain regards, but I can imagine they are significantly different in terms of approaching treatment and practice.
Finally, what are your thoughts on AI in medicine, and its possible applications (or implications) for IR?
Just wanted to say that its doctors like you who have allowed me to spend more valuable time with my grandfather, so thank you for all that you do!
Just page or email me! Happy to talk more, running out of time here.