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.
Bill Watterson, who created the best comic strip of all time (Calvin and Hobbes), gave the commencement address at Kenyon College back in 1990, which he titled, “Some Thoughts on the Real Word by One Who Glimpsed It and Fled“:
It’s surprising how hard we’ll work when the work is done just for ourselves. And with all due respect to John Stuart Mill, maybe utilitarianism is overrated. If I’ve learned one thing from being a cartoonist, it’s how important playing is to creativity and happiness. My job is essentially to come up with 365 ideas a year. If you ever want to find out just how uninteresting you really are, get a job where the quality and frequency of your thoughts determine your livelihood. I’ve found that the only way I can keep writing every day, year after year, is to let my mind wander into new territories. To do that, I’ve had to cultivate a kind of mental playfulness.
I love that line: “If you ever want to find out just how uninteresting you really are, get a job where the quality and frequency of your thoughts determine your livelihood.” Of course, Watterson had the constraints he placed on himself by his chosen medium. I don’t know if it’s easier or harder long term to do permutations pivoting around a central premise or to bounce from thing to thing as you tire and exhaust the low hanging fruit of its potential. I think they’re probably both really hard.
We’re not really taught how to recreate constructively. We need to do more than find diversions; we need to restore and expand ourselves. Our idea of relaxing is all too often to plop down in front of the television set and let its pandering idiocy liquefy our brains. Shutting off the thought process is not rejuvenating; the mind is like a car battery-it recharges by running.You may be surprised to find how quickly daily routine and the demands of “just getting by” absorb your waking hours. You may be surprised matters of habit rather than thought and inquiry. You may be surprised to find how quickly you start to see your life in terms of other people’s expectations rather than issues. You may be surprised to find out how quickly reading a good book sounds like a luxury.
I was traveling for a talk the other day and this came up with someone in the audience. I make time for the writing and the projects and the teaching/mentoring and everything else because that’s the variety that makes the more routine, potentially tedious stuff tolerable.
Yes, time management is impossible, but it doesn’t mean I wouldn’t fill more precious time with garbage if I wasn’t trying to be deliberate.
Creating a life that reflects your values and satisfies your soul is a rare achievement. In a culture that relentlessly promotes avarice and excess as the good life, a person happy doing his own work is usually considered an eccentric, if not a subversive. Ambition is only understood if it’s to rise to the top of some imaginary ladder of success. Someone who takes an undemanding job because it affords him the time to pursue other interests and activities is considered a flake. A person who abandons a career in order to stay home and raise children is considered not to be living up to his potential-as if a job title and salary are the sole measure of human worth.
You’ll be told in a hundred ways, some subtle and some not, to keep climbing, and never be satisfied with where you are, who you are, and what you’re doing. There are a million ways to sell yourself out, and I guarantee you’ll hear about them.
To invent your own life’s meaning is not easy, but it’s still allowed, and I think you’ll be happier for the trouble.
A Man for All Markets by Edward O. Thorpe is a fascinating memoir from the mathematician/gambler/investor who solved card counting and essentially invented modern quantitative investing strategies.
While reading, I was struck by two things: One, unsurprisingly, Thorpe is/was curious, industrious, and clearly a genius. Two, that his life as a latchkey kid in the early 20th century, which included buying dangerous chemicals and making amateur explosives at home could not seem more distant than the modern American screen-based and scheduled childhood.
A few standout passages:
Regarding the need to have both a desired outcome and an expected outcome in mind when making a new decision:
If you do this, what do you want to happen?
If you do this, what do you think will happen?
The problem of moral hazard in the modern US economy:
Our corporate executives speculate with their shareholders’ assets because they get big personal rewards when they win — and even if they lose, they are often bailed out with public funds by obedient politicians. We privatize profit and socialize risk.
On negotiating to “win”:
It doesn’t pay to push the other party to their absolute limit. A small extra gain is generally not worth the substantial risk the deal will break up.
The information food chain:
Be aware that information flows down a ‘food chain’, with those who get it first ‘eating’ and those who get it late being eaten.
Regulation matters, but only when simple and effective and not crafted by the schmucks making all the bad choices:
Nassim Taleb asked why, after a driver crashes his school bus, killing and injuring his passengers, he should be put in charge of another bus and asked to set up new safety rules.
How much leverage is enough?
The lesson of leverage is this: Assume that the worst imaginable outcome will occur and ask whether you can tolerate it. If the answer is no, then reduce your borrowing.
The gambler’s approach to life:
In the abstract, life is a mixture of chance and choice. Chance can be thought of as the cards you are dealt in life. Choice is how you play them.
And finally, what old people always say but young people can’t seem to internalize:
That acknowledgment, applause, and honor are welcome and add zest to life but they are not ends to be pursued. I felt then as I do now that what matters is what you do and how you do it, the quality of the time you spend, and the people you share it with.
Henrik Karlsson, from “Scraping training data for your mind,” on the need for the right kind of information to learn new skills:
[You] want the input you observe to be as closely connected to a practice as possible. You want to see the process, not just the results. The results are often misleading. If you are a musician looking at successful bands, you might get the impression that you need to make music videos to succeed, whereas, in fact, a video only makes sense after you have achieved a certain level of success—so imitating that will lead you to misallocate your time.
You will also be led astray if you rely on advice and explanations unconnected to an ongoing process. Experts can rarely articulate the behaviors that allow them to perform at a high level. The knowledge is tacit. The explanations are post-hoc rationalizations; they do not produce the results.
But if you look at the performance, if you get close to it, it is all there.
Looking at the final product to reverse engineer the process can be an impossible task. This is why seeing doctors and surgeons practice medicine and operate is so important. Why it’s so critical to have good readouts when you first start radiology training.
You need to be exposed to the unfiltered expert approach. The “teaching” isn’t just the discrete teaching points and other pearls; it’s seeing the expert practicing natively that helps create the scaffolding to incorporate book learning, real world experience, and ultimately be able to learn the most from the emotional microtraumas of repeated failure that are an unavoidable part of medical training.
Some passages on what makes a job “good” from The Happiness Hypothesis by Jonathan Haidt:
Psychologists have referred to this basic need as a need for competence, industry, or mastery. [Psychologist Robert] White called it the “effectance motive,” which he defined as the need or drive to develop competence through interacting with and controlling one’s environment. Effectance is almost as basic a need as food and water, yet it is not a deficit need, like hunger, that is satisfied and then disappears for a few hours. Rather, White said, effectance is a constant presence in our lives: Dealing with the environment means carrying on a continuing transaction which gradually changes one’s relation to the environment. Because there is no consummatory climax, satisfaction has to be seen as lying in a considerable series of transactions, in a trend of behavior rather than a goal that is achieved.
This reflects the importance of developing the craftsman mentality.
The effectance motive helps explain the progress principle: We get more pleasure from making progress toward our goals than we do from achieving them because, as Shakespeare said, “Joy’s soul lies in the doing.”
Believing the opposite was coined as “the arrival fallacy” by psychologist Tal Ben-Shahar, who wrote the best-selling Happier. (As in: I’ll finally be happy when I finish that big exam or project. No, when I graduate! Or get that promotion! No, when I retire!)
Contrast the effectance motive with the many narrowly defined clock-in clock-out closely supervised jobs that limit personal choices:
In 1964, the sociologists Melvin Kohn and Carmi Schooler surveyed 3,100 American men about their jobs and found that the key to understanding which jobs were satisfying was what they called “occupational self direction.” Men who were closely supervised in jobs of low complexity and much routine showed the highest degree of alienation (feeling powerless, dissatisfied, and separated from the work). Men who had more latitude in deciding how they approached work that was varied and challenging tended to enjoy their work much more. When workers had occupational self-direction, their work was often satisfying.
My profession of radiology can easily fall into this trap in the wrong environment. You have to carve out ways to take ownership of both the process and product.
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.
The radiologist shortage is definitely here. There are different ways to approach the market, but balancing short-term vs long-term plays is nontrivial. Leverage is great, but using too much can amplify negative downstream second-order consequences too.
What’s happening now varies and what will happen is anyone’s guess, but this anonymous op-ed “Radiologists need to be realistic about the job market” is absolutely worth reading.
…Hospitals quite literally cannot operate beyond a few hours without diagnostic radiology. We are the bottleneck for all inpatient care. All service lines run through us. Any radiologist can easily take one of the hundreds or thousands of teleradiology jobs, which offer less commute, less non-interpretive work, and often higher pay per hour. Hospital systems simply have no leverage against their radiologists except fear of the unknown.
We work in interesting times:
A group of radiologists is severely understaffed, reading far beyond what they normally would. Radiologists are overextended, and high-volume readers are threatening to quit unless something is done. The group is unable to afford hiring radiologists in the current market. Many other unsolvable issues, such as retirements, interpersonal issues, poor work ethic, interventional radiology (IR) vs. diagnostic radiology (DR) squabbles, and [plug in your practice’s problems here] plague the group. Negotiations with the hospital have yielded minimal results. What is a group to do? Take the money, or continue the negotiations?
Again, imagine all of the unsolvable problems this group may face: recruitment, billing issues, MIPS, exploding volumes during nights and weekends, older partners wanting to cut down or retire, cantankerous partners who are indispensable, ad infinitum. More money can’t solve all of these problems, because in this labor market, an exclusive contract is a massive liability. The group decides to turn these liabilities into leverage: They walk away from the contract and tell the hospital they can hire them as employees for base + productivity, or see you later.
The tables have immediately been turned. Suddenly, all of the issues that were unsolvable now become points of leverage. Can’t recruit? More leverage for us. Can’t staff weekends? More leverage for us. A couple of people retired? More leverage for those who stayed. Volume too high? I’m on productivity, or I’ll read slowly and take my base salary. Billing sucks? Not my problem. Overnight services increased their rates? Not my problem. Want to find another group? Good luck, there’s nobody else. We have three months of trailing AR to keep us fed until we get credentialed literally anywhere else.
Guess who wins?
An important pre-tax vs Roth argument that is often missed, from “Why Pre-Tax Retirement Contributions Are Better Than Roth In Peak Earning Years (Even If Tax Rates Increase)“:
The most powerful argument for a pre-tax account as a retirement savings vehicle is that it comes with the option to convert the pre-tax dollars in the account to Roth at any time. That is to say, the account owner can choose when they want to be taxed on the funds in the account (which is what happens when pre-tax funds are converted to Roth), and make those dollars tax-free from that point on. Which makes it very useful to have pre-tax funds available to convert to Roth in years with lower-than-normal income, such as the years between retiring and beginning Social Security and/or RMDs. During this time, the funds can be converted to Roth and taxed at a lower rate than they would have been during high-income working years, or in later years when Social Security and RMDs push the owner into a higher tax bracket.
Notably, Roth accounts do not have this option: There’s no way to move funds from a Roth to a traditional account and take a tax deduction in a higher-than-normal income year (i.e., the opposite of what someone would do with a Roth conversion). The ability to choose when income is recognized only goes in one direction, from traditional to Roth. So from a tax timing perspective, it’s more valuable to have pre-tax funds, with the possibility of converting them to Roth during lower-income years, than to have Roth funds that stay Roth no matter what.
Which is ultimately why, even if tax rates are expected to go up at some point in the future, it can still make sense to contribute to a pre-tax traditional retirement account. Whether or not tax rates increase, the tax timing opportunities to recognize income from pre-tax accounts will still exist. For higher earners, if there’s a reasonable chance of having several low- or zero-income years after retirement, it can make sense to defer the recognition of some of their income from a higher-tax year into a lower-tax year by making pre-tax retirement contributions.
As in, the Roth conversion option gives high-earners the benefits of a Roth contribution without committing to high taxes upfront. Play your cards right and you could even take out some of that pre-tax money tax-free in retirement too. The article’s discussion of historical taxes is worth the read.
The important counterargument is that, in real life, the effective investment between a maxed-out pre-tax and Roth account is already not apples to apples. As in, $10k in a Roth has already been taxed and is therefore reflects a greater than $10k investment. Many people (including presumably most doctors) investing in pretax accounts do not take the extra money they would need to max out a Roth and invest that in a taxable account alongside their pretax contribution. It’s all a set-and-forget it payroll deduction. So, optimized tax considerations aside, many retirees will end up with more money to spend with the Roth contribution just because they saved more money upfront. The option for a Roth conversion is powerful, but it adds complexity and requires timing, two things investors often struggle with.
Both types of accounts have strengths, and all outcomes are a combination of math and behavior in a largely unpredictable tax context.
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.