Radiology joined the ranks of physician-led class action lawsuits against the ABMS member boards last week when interventional radiologist Sadhish K. Siva filed a complaint on behalf of radiologists against the ABR for (and I’m paraphrasing) running an illegal anticompetitive monopoly and generally being terrible.

You can read the full 30-page suit if you’re interested. Legal writing is generally not of the page-turning variety, but there are still some great lines.

Regarding MOC (emphasis mine):

[The] ABR admits that no studying will be necessary for [the new MOC program] OLA and that ABR “doesn’t anticipate” incorrect answers “will happen often.” ABR also confirms on its website that “[t]he goal with all OLA content is that diplomates won’t have to study.” When a question is answered incorrectly, an explanation of the correct answer is provided so that when a similar question is asked in the future it can be answered correctly. Unsurprisingly, ABR admits it does “not anticipate a high failure rate.”

In short, to maintain ABR certification under OLA, a radiologist need only spend as little as 52 minutes per year (one minute for each of 52 questions) answering questions designed so as not to require studying, and for which ABR anticipates neither incorrect answers nor a high failure rate.

Because OLA has been designed so that all or most radiologists will pass, it validates nothing more than ABR’s ability to force radiologists to purchase MOC and continue assessing MOC fees.

Burn!

Though not called out in the lawsuit, this argument also applies to the Certifying Exam (a second, superfluous exam taken after the Core Exam, after graduating residency, and after already practicing independently as a radiologist). This may be in part because the angriest radiologists are the ones who paid for and then passed what should have been a 10-year recertification exam only to be told they had to start shelling out and doing questions right after. But the main reason is likely that the suit primarily asserts that the monopolistic behavior at play includes the ABR illegally tying mandatory MOC to its “initial certification product,” and the Certifying Exam—though suspect–is part of the initial certification process.

Interesting fact that I did not know about MOC & the insurance market:

In addition, patients whose doctors have been denied coverage by BCBS because they have not complied with MOC requirements, are typically required to pay a higher “out of network” coinsurance rate (for example, 10% in network versus 30% out of network) to their financial detriment.

It’s amazing how these organizations, which are completely unaccountable, have become such integral parts of so many different components of the healthcare machine from hospital credentialing to insurance coverage.

Speaking of that power:

The American Medical Association (“AMA”) has adopted “AMA Policy H-275.924, Principles on Maintenance of Certification (MOC),” which states, among other things, that “MOC should be based on evidence,” “should not be a mandated requirement for licensure, credentialing, reimbursement, network participation or employment,” “should be relevant to clinical practice,” “not present barriers to patient care,” and “should include cost effectiveness with full financial transparency, respect for physician’s time and their patient care commitments, alignment of MOC requirements with other regulator and payer requirements, and adherence to an evidence basis for both MOC content and processes.” ABR’s MOC fails in all of these respects.

And lastly:

[The] ABR is not a “self”-regulatory body in any meaningful sense for, among other reasons, its complete lack of accountability. Unlike the medical boards of the individual States, for example, as alleged above, ABR is a revenue-driven entity beholden to its own financial interests and those of its officers, governors, trustees, management, and key employees. ABR itself is not subject to legislative, regulatory, administrative, or other oversight by any other person, entity, or organization. It answers to no one, much less to the radiologist community which it brazenly claims to self-regulate.

Final burn!

Whether or not the suit will convince a jury that an illegal monopoly is at play, I don’t know. I can take a pretty confident educated guess as to what radiologists are rooting for. It’s pretty clear that while MOC can engender a controversy, the ABR’s efforts can’t meaningfully impact the quality of radiology practiced by its diplomates or have a significant effect on patient care.

There are many institutions/practices with well-defined “normal” templates for all types studies, which help provide a reasonable approximation of a house style. A clinician (or the next radiologist) has a reasonable chance of knowing where to find the information in the report. The reader can see something in the impression and quickly find the longer description in the body of the report for more information.

Templates can be brief skeletal outlines or include more thorough components containing pertinent negative verbiage. A section for the Kidneys could say “Normal” or it could say, “No parenchymal lesions. No calculi. No hydronephrosis.” Some groups have diagnosis-specific templates that build off a generic foundation to better address specific concerns like renal mass characterization or appendicitis.

Either way, some form of templating is a helpful forcing function to creating a readable report. After all, radiology for better or worse is a field where the report is the primary product, and creating reports that are concise, organized, and readable should be a goal.

Some institutions and practices do not have these baseline templates. There are (often but not always older) attendings who seem to not only practice but respect the freewheeling old school transcriptionist style of reporting. A resident who doesn’t “need” a template is to be prized and congratulated.

This isn’t 100% wrong either. It’s a useful ability in the sense that it’s important to be able to summarize findings in cohesive English. It’s largely the same skill as the casemanship skills used during hot-seat conferences that the recent Core exam generation of residents have largely lost, and so I can appreciate this perspective. However, at least from a reporting perspective, this is suboptimal in the 21st century.

The purpose of the radiology report

The first attending I ever worked in radiology was a neuroradiologist who posed a semi-rhetorical question on my first day. He used to ask:

What is the purpose of the radiology report?

The answer, he argued, was to create the right frame of mind in the reader.

I think this view is exactly right.

Defined in a narrow sense, this means that the reader should come away with the impression that you intend for them to have. If something is bad and scary, that should be clear. If something is of no consequence, that should also be clear. Items in the impression are there because we want those impressed on the minds of our readers, not just because we saw them.

With increasing patient access to radiology reports, we now have a second audience. While doing away with all medical and radiological jargon is probably misguided and unnecessary, we need to at least be cognizant of how our reports might read to a layperson (or non-specialist, for that matter). If we can be more clear and more direct, we have a greater chance of communicating effectively to all involved parties.

Templates make reports more organized and scannable. Not even debatable.

But while the primary intent of “frame of mind”-creation may relate to the significant radiological findings, it’s also about creating the right frame of mind about you, the radiologist. Thorough, thoughtful, organized, conscientious? Or rushed, disorganized, careless, apathetic?

There may be some perks of blinding readers with science and drowning readers in long-winded descriptions of even benign and irrelevant incidental findings. At least you won’t look lazy! But for the less verbose among us, we can show we care by creating reports that reflect our systematic approach and clear writing style. Templating creates digestible reports.

Lastly, as quality metrics rise in importance and resource utilization re-enters the arena as a responsibility of the radiologist, we also need our reports to be readable and indexable by computers. The easier our reports are to parse, the easier we can extract meaningful data about our findings, link these up with patient data from the EMR, and draw high-powered conclusions about patient impact, outcomes, and (of special importance to me) the utility of certain exams in specific clinical contexts.

Dictation software is a tool, not a recorder

If you’re a resident somewhere and your institution doesn’t have power normals to frame-out your reports, make some. If you find yourself saying the exact same things over and over again every single day, then you’re doing it wrong. It should either part of the template or an auto-text macro (tip: In PowerScribe, highlight the text you want to save and say “macro that”). If nothing else, it will reduce your rate of transcription errors.

No one needs to reinvent the wheel on every case!

It was super duper gratifying to receive my first OLA email from the ABR this past month. OLA (Online Longitudinal Assessment) is the ABR’s new longitudinal MOC (Maintenance of Certification) process, where diplomates take 52 questions every year instead of a big test every decade.

I took the Certifying Exam in October and received my passing result in November, so the month-long break prior to needing to “maintain” my brand new certification from the ABR feels just about right. Yes, a thousand folks need to maintain a piece of paper they haven’t actually received in the mail yet. I can appreciate why folks fresh off their q10-year MOC victory are irritated at needing to immediately participate in more MOC. Promises are being broken left and right. But, hey, money.

Adding insult to injury, as a neuroradiologist, I still have to sit for the exorbitantly expensive ($3,270) neuroradiology subspecialty exam this October. Which means that I need to maintain my first certification in between getting my second.

The final irritant in this system of paying $340/year (forever) is that the ABR, which is a nonprofit sitting on a war chest of ~$48 million, didn’t apply for (i.e. pay for) ACCME accreditation, so the hours spent doing OLA questions don’t count as official CME. (Update Feb 2020: Now they do, reducing your SA-CME burden from 25 to 15 hours over the 3-year period for MOC attestation)

The Actual OLA Experience

The current OLA paradigm is that 2 questions are released every week (104 a year) and “expire” after 28 days. So while you can log in and batch around 8 questions a month, you won’t be able to do it less often without losing some expired questions. Since you only need 52 questions and can do around 8 a month, you could actually get away with doing it almost bimonthly.

I took my first 8 questions this week and got them all right. They were straightforward, reasonable, and relevant to practice (at least in neuroradiology). My initial impression is that OLA questions are more like what the Core exam should be. You get between 1-3 minutes per question, the website was pretty slick (at least on a desktop), and I did all 8 in around 5 minutes. Can’t complain there. This is clearly a better system and more logical way to fulfill the spirit of MOC than taking an exam full of (even more) irrelevant material every decade.

You get to choose your practice profile and thus what types of questions you receive. I originally chose general diagnostic radiology and neuroradiology, but out of my first 8 questions, 7 were neuro and only 1 ended up being general, and the general question concerned GI fluoroscopy, which I detest, so I switched to 100% neuro. Maybe it’ll help with the subspecialty exam.

Things the ABR should improve:

• Mobile experience. I’ve heard complaints about display issues on phones. You only get a minute for most questions, so it needs to work.
• Lower the price. At the current rates, this is far more expensive than any commercial qbank. And that’s what this is. The ABR makes a lot of profit for a non-profit.
• Increase question shelf-life. Why do questions expire after 28 days? So arbitrary. Let the radiologists hold themselves accountable. How about 90?
• Get official CME accreditation. This feels like apathy and laziness. I know it’s not straightforward or cheap to be a CME-granting organization with the ACCME. But again, this is an expensive process, but it would be far more reasonable if it counted for CME. (Update Feb 2020: They don’t give you hours per se, but they do reduce the obligation for SA-CME for MOC; you’ll still have to satisfy your state requirements)

And finally, how about you let everyone take the certifying and subspecialty exams using the OLA software instead of flying out to Chicago to waste their time?