From Intern to Imaging: Tips for Thriving as an R1

Niki Nourmohammadi, DO, MPH, Education Liaison of the ACR® Resident and Fellow Section, contributed this piece. Dr. Nourmohammadi is a post-graduate third-year diagnostic radiology resident for Larkin Health System, Florida.

Murky Transition

Transitioning from intern year into radiology residency is an uneasy shift. During your internship, you gradually gain confidence in providing clinical care. Much of what you learned in medical school still applies: You manage patients, field pages and sometimes make independent decisions, especially on night shifts.

Then suddenly, on day one of residency, it feels like you’re starting your medical training all over again. Your autonomy disappears. With limited exposure to radiology during medical school or internship, much of your prior knowledge no longer fully applies. You’ve reverted to a student-like role, watching attendings rewrite your reports line by line. After years of steadily “leveling up” through med school and internship, it feels like you’ve been reset to zero. That sense of disorientation isn’t unusual; it’s normal. In fact, it should be expected.

Slow Is Smooth | Smooth Is Fast

I’m not a weightlifter (I’m barely five feet tall with T-rex arms and struggle to open heavy doors), but there’s a weightlifter saying — slow is smooth; smooth is fast — that applies beautifully to radiology training.

Early on, the pace of learning can feel painfully slow. Anatomy is overwhelming, pathology is endless and the PACS worklist never stops populating. But if you take the time to build a strong foundation — learning to describe what you see, checking the operative notes, correlating with pathology — your growth accelerates later. Smooth eventually becomes fast.

External vs. Internal Motivation

Unlike medical school, radiology training doesn’t have Step 1 or periodic shelf exams to provide constant external pressure. The ACR offers residents both remote and in-person training testing on an annual basis, but most of your external motivation will arise in an effort to avoid stumbling on something basic during readouts. Long-term motivation is different; it’s rooted in personal investment.

Every hour you spend reading, studying or reviewing pathology reports directly translates into better patient care in the future.

It’s easy to feel disconnected from being a “real doctor” as an R1 when you’re sitting behind your attending, watching them edit your reports and not directly managing patients. But one day, you will be the one calling the shots; and you must be ready. Don’t wait until Qualifying (CORE) Exam prep to start learning radiology. Build the right habits now.

The ACR Continuous Professional Improvement (CPI) program provides current, content-rich casework to build your subspecialty knowledge in essential areas of ABR-required study. And you can use your ACR RFS member-in-training discount to save more than 75%. 

Formulate a Game Plan

One of the challenges in R1 year is much of the growth falls on your own shoulders. That’s why it’s crucial to create a plan. Before each rotation, decide what you want to master. For example, on chest, maybe focus on interstitial lung disease patterns. On neuro, get comfortable with stroke protocols.

Set aside time every day for textbook study, practice cases or videos. Do not depend on the worklist alone to give you the spectrum of pathology you need to see. Be sure to check out the Getting Started — A Guide to Year One of Radiology Residency and sign up for your daily ACR Case in Point® email. This allows you to review a new case each day to improve your skills by assessing findings and diagnosing conditions.

Track your progress, whether by keeping a journal, notes or a simple spreadsheet, so you can revisit tough concepts and monitor what you’ve gained over time. Just like in medical school, consistency matters more than intensity. But unlike med school, you don’t need eight-hour cram sessions. What you need is steady, daily engagement.

Make the Most of R1 Free Time

As an R1, you’ll have more free time than at any other point in residency. By R2, research projects, leadership roles, independent call and night float start to pile up. By R3, you can add fellowship applications, interviews and the all-consuming Qualifying (CORE) Exam prep. And by R4, you’re balancing fellowship responsibilities, job searches and often moonlighting on top of it all.

Use this year wisely. Start a research project and finish it. Submit to a conference. Go to national meetings and introduce yourself to attendings, mentors and peers. Most importantly, focus on building connections and finding interests outside the reading room.

You might also consider taking a look at ACR fellowships and grants as many are open to year-one residents such as ACR Institute for Radiologic-Pathology™ (AIRP®) fellowships, the Richard L. Morin, PhD, Fellowship in Medical Physics and the Goldberg-Reeder Resident Travel Grant. 

Learn From Pathology and Surgery

One of the best pieces of advice I received was to “talk to the pathologist.” Radiology doesn’t exist in a vacuum; every scan eventually collides with a pathology report, an operative note or a clinical outcome.

Courses for residents from AIRP show the pathological basis for a broad range of diseases, including the Four-Week Radiologic Pathology Correlation and the free Healthcare Delivery & Policy Research course.

I’ve had cases where what we thought radiologically didn’t line up with surgical or pathology findings. That mismatch was frustrating, but it taught me more than any textbook. Make it a habit to follow up. Ask, “What did the biopsy show? What did the surgeon find?” It will sharpen your eye and deepen your understanding.

Don’t Fear the Challenging Cases

It’s tempting as an R1 to cling to the easy ones: The obvious appendicitis, the textbook pneumonia. But growth comes when you wrestle with cases you don’t understand.

If you don’t know what something is, describe it in detail: Size, shape, density, margins, enhancement. Even if you can’t name it, you’ll often stumble onto the answer by working through the description systematically.

This approach also pairs well with AI tools. With the rise of AI in radiology education, an accurate description can yield a set of differentials that help you narrow down possibilities. Garbage in, garbage out; so, learn to describe first, diagnose second.

The ACR offers many resources for leveraging AI and emerging technologies for healthcare such as data science and informatics tools, resources and support, including the ACR Data Science Institute® (DSI), ACR AI-LAB®, a full library of interpretive and noninterpretive use cases organized by subspecialty and category, and DSI use case videos.

Managing the Ego Hit

Let’s be honest: It stings when your carefully crafted report gets highlighted, deleted and rewritten from scratch. The truth is, every R1 goes through this. The sooner you accept that ego hit, the faster you can move forward. Radiology is a long game.

By the time you’re on independent call, you’ll realize just how far you’ve come. To proactively manage those hits, the ACR Radiology Leadership Institute® offers many tools and resources for residents, including the Career Confidence Collection designed to help you prepare for the future.

Closing Thoughts

Starting radiology may feel like you’re being thrown into the deep end with floaties that you’re not sure how to inflate. Every radiologist before you has been there, and every attending you admire started just as lost.

You’re not going backward. You’re building the foundation for the radiologist you’re becoming.