They used to say academics was less production/pay and private practice was high stress/high comp. The gap has narrowed because the academy is demanding much more, lots of rads are just nonacademic employees of the university behemoth working a generic job, and the labor shortage means hospitals/universities need to pay more to compete in the job market.
Perhaps counterintuitively, strong private practice in the face of the labor shortage is one of the factors driving up academic compensation.
Add this to the list of things that I should have had ready for launch day back in August: the Independent Radiology Newsletter. Sign up now to receive monthly job updates from the world of private practice radiology.
It’s an incredible privilege to work at a place and live in a country that is willing to set aside money to answer these existential questions. I heard a phrase the other week, existential humility, and I really liked that. We’re this complex life form that has evolved over billions of years to the point where we can ask these questions — and yet we’re perhaps not the only ones in the universe. And if we could know that for certain, that would be humbling in the most wonderful possible way.
– Astronomer Vanessa Bailey in Dave Eggers’ “The Searchers,” a profile on NASA’s Jet Propulsion Lab.
If you haven’t yet read an explainer on “AI”, I consider Jeremiah Lowin’s “An Intuitive Guide to How LLMs Work” to be a good one.
Another paper suggesting that clinicians prefer some structure (but not too much structure) in radiology reports. There are always edge cases where structured reporting becomes cumbersome–and overly parsed reports are also inefficient/unreadable–but there’s no denying it’s so much easier for me to scan a prior report when it’s not narrative free text.
A reader asked if anyone had successfully started a new radiology private practice recently, particularly one that involved financing, opening up new imaging centers, and fresh payor contracts. There is a vacuum in some areas, especially with the PE-exacerbated instability, and therefore a clear opportunity to those who can muster the manpower (no easy feat).
As a follow-up, I thought I’d ask (on their behalf): is anyone who has willing to mentor other upstarts?
The month of August has been almost exclusively related to the usual activities of daily living and the new/growing job board I’ve started dedicated to true independent physician-owned radiology private practices, which now has 45 groups. I know a service like Independent Radiology probably has more impact than my usual sporadic writing, but I’m personally looking forward to getting back to my usual idiosyncrasies in September.
An interesting essay by Leopold Aschenbrenner discussing the recent history of as well predictions for the next 10 years of AI: “From GPT-4 to AGI”
A long but good read, which itself is part of an even longer series.
Forget about AI taking your job, maybe we’ll all just live forever.
From “Writer Math” by Elissa Bassist in McSweeney’s:
If you think a piece is 100 percent done, it’s actually 45 percent done. To get it to 100 percent done, you can’t.
The tale of case review at Cigna in ProPublica:
“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”
[…]
The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.
[…]
As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases.
If you have HBO Max, standup comic Alex Edelman’s one-man show was excellent. The official description of its main narrative thread: “In the wake of a string of anti–Semitic threats pointed in his direction online, standup comic Alex Edelman decides to go straight to the source; specifically, Queens, where he covertly attends a meeting of White Nationalists.” Here’s the trailer.
On April 23 at 2 pm ET, the FTC is holding a special open meeting with a live webcast to discuss the proposed final rule banning most noncompete clauses. At the end of the meeting, “the Commission will vote on whether to issue the final rule.”
Potentially huge news (that will then immediately be challenged legally).
I got an underdesk elliptical a couple of weeks ago…I think maybe it’s awesome and wish I had gotten one a long time ago. I’m honestly a little surprised I can pedal while thinking.
I tried a few, and this is the one I landed on: very stable, pretty cheap, reasonably quiet.
In which we have the nonphysician CEO of the largest radiology company/practice in the country—one that employs 10% of the workforce, just received $720 million in rescue funding, and is valued at several billion dollars—taking the time to troll an individual radiologist on X (née Twitter):
Clearly, a man delighting in his bailout.
I’m running low on my stash of Cometeer coffee. If you’re interested, you can get $20 off your first order and help subsidize my terrible caffeine addiction. (Full review here. Not an ad, but I do like cheaper coffee.)
Another wide-ranging radiology conversation, this time for an episode with the resident-run radiology podcast, Clinically Correlate.
For those with an extra ~50 minutes in their lives, Daniel Arnold and I had a wide-ranging conversation on the newest episode of the Radiology Report podcast.
Lower [neuroradiology] shift volumes yielded significantly lower error rates. The lowest error rates were observed with shift volumes that were limited to 19–26 [CT/MRI] studies. Error rates at shift volumes between 67–90 studies were 226% higher, compared with the error rate at shift volumes of ≤ 19 studies.
I wonder, are there any places in the world routinely reading ~20 cases per shift?
C.S. Lewis (of Narnia fame) on peer learning:
It often happens that two schoolboys can solve difficulties in their work for one another better than the master can. The fellow-pupil can help more than the master because he knows less. The difficulty we want him to explain is one he has recently met. The expert met it so long ago he has forgotten.
I’ve always been a big proponent of peer teaching and peer mentoring in medicine. I also often wonder if I’m getting worse at teaching the basics as I get older.
Radiology Partners is in the news more (especially now), but here’s an interesting compare/contrast from S&P back in March 2023 looking at RP vs US Radiology (free account required).
From that, an interesting chart for a bird’s eye view:
Note: this chart is almost a year old and predates a lot of recent developments including RP’s proposed recent restructuring and USRS’s launching of its outpatient teleradiology practice Connexia.
Long but good read: “The pharma industry from Paul Janssen to today: why drugs got harder to develop and what we can do about it” by Alex Telford.
From “How to Do Great Work” by Paul Graham:
Schools also give you a misleading impression of what work is like. In school they tell you what the problems are, and they’re almost always soluble using no more than you’ve been taught so far. In real life you have to figure out what the problems are, and you often don’t know if they’re soluble at all.
Schools sometimes also give students the misleading impression that learning is not fun for its own sake and that writing should be boring.
From “The Bitter Lesson” by Rich Sutton:
In speech recognition, there was an early competition, sponsored by DARPA, in the 1970s. Entrants included a host of special methods that took advantage of human knowledge—knowledge of words, of phonemes, of the human vocal tract, etc. On the other side were newer methods that were more statistical in nature and did much more computation, based on hidden Markov models (HMMs). Again, the statistical methods won out over the human-knowledge-based methods. This led to a major change in all of natural language processing, gradually over decades, where statistics and computation came to dominate the field. The recent rise of deep learning in speech recognition is the most recent step in this consistent direction. Deep learning methods rely even less on human knowledge, and use even more computation, together with learning on huge training sets, to produce dramatically better speech recognition systems. As in the games, researchers always tried to make systems that worked the way the researchers thought their own minds worked—they tried to put that knowledge in their systems—but it proved ultimately counterproductive, and a colossal waste of researcher’s time, when, through Moore’s law, massive computation became available and a means was found to put it to good use.
[…]
We want AI agents that can discover like we can, not which contain what we have discovered. Building in our discoveries only makes it harder to see how the discovering process can be done.
In addition to being New Year’s, this site turned 15 years old (!) today. It contains hundreds of posts, over a half million words, and oodles of my time.
Thanks for reading!
My crystal ball is as cloudy as ever.
Earlier this month I wrote about Radiology Partners loaning a group money to help shore up radiologist compensation. That happened, but I was also wrong in my estimation of the likelihood of repayment: it turns out RP may be getting some of that money back after all.
The ultimate outcome is still up in the air, but I’ve addended my previous post with an update.
From “Serious Medical Errors Rose After Private Equity Firms Bought Hospitals,” reported by the NYT:
The study, published in JAMA on Tuesday, found that, in the three years after a private equity fund bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.
“We were not surprised there was a signal,” said Dr. Sneha Kannan, a health care researcher and physician at the division of pulmonary and critical care at Massachusetts General Hospital, who was the paper’s lead author. “I will say we were surprised at how strong it was.”
In honor of the late great Charlie Munger, Stripe Press has his popular book (mental models, decision-making, stuff like this) available for free online in both a well-formatted browser-based ebook and audiobook formats: Poor Charlie’s Almanack: The Essential Wit and Wisdom of Charles T. Munger
People like to operate under the belief that services like anesthesia, radiology, and pathology are totally interchangeable commodities. We do the work but don’t generate it, and patients generally don’t get to pick.
But in the real world, labor isn’t as cog-like as you might think, and culture matters (yes, even in our dysfunctional healthcare system).
Here, enjoy this story of a failed private equity anesthesia takeover.
Making a compilation list of links to Dr. Lea Alhilali’s excellent neuroradiology “tweetorials” was literally on my to-do list, but now her threads are all collected on Radiopeadia (so I don’t have to).
The UnitedHealthcare vs Radiology Partners lawsuit went to arbitration instead of a jury trial last month. Last week, the arbitration panel ruled in favor of RP and its practice Singleton Associates, awarding them $153.5 million.
United, for its part, says it’s not done, and that there are still unaddressed counterclaims. From that Radiology Business article: “We do not agree that Singleton will recover an award from UnitedHealthcare,” the Minnetonka, Minnesota, company said.
Two great quick radiology podcasts, well worth your time for a better understanding of radiology in 2023:
First, the state of the radiology residency match and how things look for medical students as well as the radiology workforce, courtesy of Dr. Francis Deng (@francisdeng). I agree with everything he said, and he said it better than I would have. Listen here.
Second, episode 2 of the Texas Radiological Society’s “How Radiologists Get Paid” Podcast: a great discussion of the state of payment policy between Dr. Kurt Schoppe, policy wonk and my colleague across town, and Dr. Lauren Nicola, current Chair of the Reimbursement Committee at the ACR. If you want a better understanding of CMS reimbursement and what “quality” has meant recently in radiology, check it out.
From “COMMON PROVERBS AS VIDEO GAME TUTORIALS” in McSweeney’s:
Notice how after you consumed the Cake, the Cake is no longer in your inventory.
From the short essay, “Energy Makes Time,” by Mandy Brown:
But there’s something else I want to suggest here, and it’s to stop thinking about time entirely. Or, at least, to stop thinking about time as something consistent. We all know that time can be stretchy or compressed—we’ve experienced hours that plodded along interminably and those that whisked by in a few breaths. We’ve had days in which we got so much done we surprised ourselves and days where we got into a staring contest with the to-do list and the to-do list didn’t blink. And we’ve also had days that left us puddled on the floor and days that left us pumped up, practically leaping out of our chairs. What differentiates these experiences isn’t the number of hours in the day but the energy we get from the work. Energy makes time.
The what is sometimes even more important than the how much.
From the free ebook A Manifesto for Applying Behavioral Science from the UK’s Behavioural Insights Team:
The other concern is that [behavorial science] theories can make specific predictions, but they are disconnected from each other – and from a deeper, general framework that can provide broader explanations (like evolutionary theory, for example). The main way this issue affects behavioral science is through heuristics and biases. Examples of individual biases are accessible, popular, and how many people first encounter behavioral science. These ideas are incredibly useful, but have often been presented as lists of standalone curiosities, in a way that is incoherent, reductive, and deadening. They can create overconfident thinking that targeting a specific bias (in isolation) will achieve a certain outcome.
Cognitive biases and mental models make for great blog posts but are really hard to put into practice as an individual or effectively guide policy as an organization.
For further reading, try Nudge (the new/final edition was just released in 2021).
In a similar vein to our recent discussion of radiology practice and game theory, this is from Andrew K. Moriarity’s new article in JACR, “Pirate Practice”:
Employed sailors could count on the guarantee of agreed-upon pay in return for work performed. However, each pirate must be primarily motivated to ensure group success by their own self-interest because each endeavor lasted only as long cooperation maximized profits over expenses.
[…]
In considering the cooperation needed among individuals for a successful voyage to keep moving forward, perhaps Jack Sparrow was right to conclude that “not all treasure is silver and gold, mate.”
Humans–with some incredible diligence and lots of practice–can do such fascinating things.
Pretty unreal.
Hold in the back of your mind the notion that someday you’re gonna write a book. You don’t have to write it this year. Meanwhile, writing begets writing. Just get into some kind of situation where you are writing, and if it’s some various thing you’re publishing online, it’s still grist to the mill.
Legendary nonfiction writer John McPhee in an interview with GQ at the tender age of 92. For further reading, see Draft No. 4.
From Tanner Greer’s The Scholar’s Stage:
The professionalization of intellectual pursuit is another problem. Melville would never have written Moby Dick if he had spent years enrolled in an MFA program instead of spending years at sea. Men and women who in past ages would have observed humanity up close (or at least who would have been forced through a broad but rigorous education in classics) instead cloister themselves in ivory towers. Their intellectual energy is channeled into ever more specialized academic fields and cautiously climbing a bureaucratic and over-managed academic ladder. Could that social scene ever produce a great work?
Great reporting by Cezary Podkul in ProPublica (and amazing perseverance by Dr. Shteynshlyuger):
A powerful lobbyist convinced a federal agency that doctors can be forced to pay fees on money that health insurers owe them. Big companies rake in profits while doctors are saddled with yet another cost in a burdensome health care system.
“Our Economy Is Being Plundered By Wall Street Elites” is fantastic discussion of private equity in America on the Wealthion Podcast. It’s an interview with Gretchen Morgenson, Pulitzer-prize winning author of the new bestselling These Are the Plunderers: How Private Equity Runs―and Wrecks―America. If you’ve been wanting to learn more about the industry but haven’t had the time, this is a great introduction.
I’ll be giving the keynote at the FSU College of Medicine’s Business & Medicine Symposium in Tallahassee this Saturday. If you’re a student there, make sure to come say hi during the morning coffee or lunch after!
On my brief perusal, the eBook for Undergraduate Education in Radiology (developed by the European Society of Radiology) seems like a great and entirely free first radiology book for medical students and first-year residents. In particular, the sections I looked at included a great first pass of high-yield anatomy. Strongly recommended.
How amazing does this new retro NES-themed mechanical keyboard look?
And an included separate pad with two huge programmable buttons?
That’s a great way to toggle dictation or almost have fun navigating Epic.
$39 billion of student loans were forgiven tax-free this month.
If you have any FFEL, Perkins, or Health Education Assistance Loan (HEAL) Program loans, please check out the IDR Waiver FAQ. You have until the end of 2023 to do a Direct Consolidation to make those loans eligible for loan forgiveness programs and count previous payments without resetting the clock.
Filed under things I really want but for way, way cheaper: Project E Ink’s “$2500 e ink art piece that displays daily newspapers on your wall.”
From MONETIZING MEDICINE: PRIVATE EQUITY AND COMPETITION IN PHYSICIAN PRACTICE MARKETS, a report by the American Antitrust Institute:
Price increases associated with PE acquisitions are exceptionally high where a PE firm controls a competitively significant share of the local market. When we focus our analysis on markets where a single PE firm controls more than 30% of the market, we find further elevated prices associated with PE acquisitions in each of the 3 specialties with statistically significant results, for gastroenterology (18%), obstetrics and gynecology (16%), and dermatology (13%).
Discussed in the NYTimes here.
Jeff Goldsmith in “What Can We Learn from the Envision Bankruptcy?“:
Strategically, the Envision bankruptcy raises anew the question of whether there are economies of scale, and investment returns to scaling, in healthcare. Certainly the conventional wisdom argued that large firms like Envision had the ability to recruit and retain clinicians across vast geographies, and negotiating power with the large insurers that increasingly dominate key insurance sectors like Medicare Advantage and Managed Medicaid.
Envision’s demise strongly suggests that the power balance-both political and economic- has tipped decisively in the direction of payers like United. Rising interest rates, the increasing scarcity of clinicians as workaholic baby boom vintage docs and deepening financial challenges for the ultimate customers of many of these companies, namely hospitals, suggest that we may have reached an inflection point in the viability of many private equity physician care models, with their 4-7 year holding periods and a succession of owners. Current owners might find it increasingly difficult to exit their positions.
CEO’s Skill Set Transferable To Any Job That Requires Dumbass To Receive Big Salary: “I have the incompetence necessary to effortlessly transition into a role at any company that yields a seven-figure income.”