Ben White

Ultralearning Radiology

06.20.23 // Radiology

The science of learning has become a lot more popular over the past few years than when I was a student. Contemporary medical students utilize spaced repetition algorithms for their Anki flashcard decks, enjoy high-quality question banks, watch videos at 2x speed, and drill with picture-based mnemonic tools like Sketchy Medical. These techniques have minimal overlap with the medical school I started fifteen years ago (in-person lectures, books, repeat).

A lot of the most compelling educational literature forming the basis for our current conception of optimal learning is well-summarized in the book Make it Stick (the big three being [1] spaced repetition, [2] retrieval practice, and [3] interleaving). A less academic and more casual book repackaging of this evidence-based approach is Ultralearning by Scott Young. I wrote about it back in 2020 in this post about the transfer problem.

We can summarize Young’s key components of “ultra” learning as Directness, Drill, Retrieval, Feedback, Retention, Intuition, and Experimentation.

This post is meant to prompt you to do the work of meta-learning: learning about learning, trying to figure out the best ways to learn the art and science of practicing radiology.
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The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”

From “The Moral Crisis of America’s Doctors.”

// 06.15.23

RadPartners’ Debtholders Are Lawyering Up

06.12.23 // Radiology

In Bloomberg Law, “Radiology Partners’s Lenders Seek Counsel as Debt Wall Looms“:

Some lenders to Radiology Partners are consulting with lawyers at Gibson Dunn & Crutcher to explore its options ahead of looming debt maturities, according to people with knowledge of the situation.

The ad hoc group holds more than 50% of Radiology’s term loan, said the people, who asked not to be identified because the matter is private.

Radiology Partners, a group of radiology practices, has a $440 million revolver due in November 2024, which will become current in about six months. It then has a $1.6 billion term loan and $800 million of secured notes maturing in July 2025.

Not “private” enough that they could resist the chance to try to turn the screws on RP publically.

This is, of course, hot on the heels of the recent S&P downgrade, cashflow problems, and United lawsuit on a background of recent PE bankruptcies including Envision.

Graduating medical students: if you haven’t already begun, it’s around time to consolidate your federal student loans. The benefits are discussed in this chapter from my (free) book. While you’re at it, you should also probably read the whole thing.

// 06.11.23

Confidence in RadPartners Continues to Fall

06.08.23 // Radiology

As reported by Radiology Business, S&P has downgraded Rad Partners’ credit rating from B- to CCC+ (from vulnerable to speculative/junk)

The full descriptions of those ratings are here:

An obligation rated ‘B’ is more vulnerable to nonpayment than obligations rated ‘BB’, but the obligor currently has the capacity to meet its financial commitment on the obligation. Adverse business, financial, or economic conditions will likely impair the obligor’s capacity or willingness to meet its financial commitment on the obligation.

An obligation rated ‘CCC’ is currently vulnerable to nonpayment, and is dependent upon favorable business, financial, and economic conditions for the obligor to meet its financial commitment on the obligation. In the event of adverse business, financial, or economic conditions, the obligor is not likely to have the capacity to meet its financial commitment on the obligation.

As in, S&P doesn’t really believe RP can meet its debt obligations unless “favorable” conditions arise. I’ve reported on RP’s financial/PR problems before, including delays in profit-sharing just last week.

There was a great line referenced in the RBJ article that I’m not sure was intended as written or just an amazing Freudian slip (emphasis mine):

“That said, we also understand Radiology Partners’ cost saving initiatives, increased focus on organic growth rather than acquisitions, continued efforts to manage labor market conditions and ability to increase subsidies from providers, will eventually improve profitability and credit metrics,” analysts noted.

Assuredly RP is trying to get subsidies from its hospital contracts, but I suppose in many ways they are also keen on extracting subsidies from their radiologists as well.

Perhaps the recent management resignations (including the Senior VP of Finance and VP of Human Resources so far) are no coincidence either:

S&P said its downgrade also reflects RP’s corporate decision-making, which “prioritizes the interests of the controlling owners, in line with our view of the majority of rated entities owned by private-equity sponsors.”

You can read S&P’s announcement here.

Hi! I’ve been wanting to revamp my site for years, but some mandatory security updates have forced my hand, so now we’re in the middle of frantic unplanned unavoidable total website redesign (oops)!

Please excuse any quirks as I work on this in my copious free time.

// 06.07.23

Fudging with “Adjustments”

06.07.23 // Finance

From Verdad’s “Private Equity Fundamentals” (a good albeit somewhat technical read):

The sample of companies we looked at is nearly unprofitable on an EBITDA basis, mostly cash flow negative, and extraordinarily leveraged (mostly with floating-rate debt that is now costing nearly 12%). These companies trade at a dramatic premium to public markets on a GAAP basis, only reaching comparability after massive amounts of pro-forma adjustments. And these are the companies that most likely reflect the better outcomes in private equity. The market and SPAC boom of 2021 presented a window for private equity and venture capital firms to take companies public, and private investors took public what they thought they could. Presumably, what remains in the portfolios was what could not be taken public.

Resolving these challenges will be difficult. Growth seems more challenging in a wobbly economy, and the tailwind of rising multiples has disappeared. Private equity sponsors will likely need to have difficult conversations with their lenders and focus on operational execution to manage costs as they navigate a less friendly macro environment. From a quantitative perspective, the fundamentals of sponsor-backed companies look frightening.

GAAP stands for “Generally Accepted Accounting Principles.” EBITDA stands for “earnings before interest, taxes, depreciation and amortization.” These companies often report adjusted “pro-forma” measures to make themselves look better:

It’s a nice summary of the house of cards.

 

COI at the ACR

06.02.23 // Radiology

I appreciate that not everyone is on Twitter—and frankly that’s probably for the best since it’s largely a toxic dumpster fire—but I did want to share this tweet/thread about a real situation unfolding at the American College of Radiology, the largest and most important radiology organization in the US. Among other things, the ACR sets standards for imaging center accreditation, creates the appropriateness criteria and incidental findings white papers we all love, influences reimbursement, and performs congressional lobbying on behalf of radiologists.

[Update: it looks like the ExitACR account got banned again. People involved in organized radiology like the ABR and ACR like to unfairly flag his/her content. The story shared in the thread was that RadPartner’s Associate Chief Medical Officer and head of Clinical Research and Education was elected to ACR leadership with his RP relationship functionally undisclosed to most voters.]

Insofar as anything involving organized radiology is newsworthy, this is news.

Who knows whether transparency here would have affected the election outcome. But we do know that this disclosure issue was debated fiercely a couple years ago, and this situation is exactly what people had in mind. I don’t know this radiologist, but it’s not just a paper relationship: he apparently went straight from the ACR annual meeting to be on stage at the RP Leadership Summit.

That said, this isn’t really a “private equity is just the worst” issue, because he apparently made the disclosures he had to make in order to follow the rules. It’s more of a problem/oversight with the ACR’s internal process compliance. However, it does reinforce how important these PE companies feel it is to infiltrate professional organizations (and especially to be high in the ACR leadership). It helps control the narrative and steer policy.

Every big democratic institution at least voices that it cares a lot about transparency and conflicts of interest. On that front, this is a big miss.