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Current Demands for Radiology Subspecialties

03.11.25 // Radiology

As of this week, Independent Radiology features 125 private practices, which gives us an interesting look at a slice of the radiology job market. Here is the breakdown of subspecialty openings today:

  • Mammo: 79% (99)
  • Body: 78% (98)
  • General: 71% (89)
  • Neuro: 66% (83)
  • MSK: 54% (67)
  • VIR: 43% (54)
  • Chest/Cardiovascular: 37% (46)
  • NM/PET: 34% (42)
  • Peds: 26% (32)
  • Neuro IR: 6% (7)

Off-hours positions are also plentiful with 39% (49) hiring swing shifts and 35% (44) hiring overnight radiologists. I suspect that those offerings reflect not just specific group needs but also an attempt to tap into the available remote workforce and meet market conditions. (That reminds me, my group has one opening for each.)

Overall, 67% (84) of groups have remote positions of some variety, and 30% (38) are willing to hire contractors in some fashion.

Open Loop Errors

03.10.25 // Medicine

From “The how we need now: A capacity agenda for 2025 and beyond,” published by the Niskanen Center think tank:

We need a new operating model for government if we are to restore our capacity to achieve our policy goals. This model must close the open loop we described in Part 3: a one-way system from law- and policy-making to implementation to real world outcomes that offers little space for learning and adjustment along the way. We can no longer rely on media coverage and elections, blunt tools that tend to be saved only for the most catastrophic errors, as the main corrective mechanisms.

Closing the loop means that we must apply test-and-learn approaches. This means conducting multiple small-scale experiments at the boundaries of policy and delivery — and doing this permanently, in pursuit of a policy intent or outcome. Incremental changes are scaled up once there is good evidence they work in reality. Test-and-learn does not mean simply running lots of pilots. A pilot implies starting with a phase for learning, which then ends as you move into “roll out.” Responsiveness is an embedded attribute, not a phase on a timeline. Closing the loop means the learning doesn’t stop at an arbitrary moment.

We briefly touched on this paper before and the concept of the Cascade of Rigidity “that occurs when well-intentioned laws and regulations become increasingly inflexible as they step down through bureaucratic hierarchies.” They discuss a healthcare-related Open Loop error with MACRA:

MACRA (Medicare Access and CHIP Reauthorization Act) was designed to pay doctors more for higher-quality care. But an implementation team at the Centers for Medicare and Medicaid Services (CMS) knew that doctors were already frustrated with the burdensome and confusing ways they had to report their data under the existing program, and many were so concerned that the new system would be just as bad that they were threatening to stop taking Medicare patients. Thus, a law designed to improve the quality of care threatened to degrade it, especially for patients in rural areas who relied on the small practices that were most affected.

Recognizing how challenging the administrative requirements could be for practices with fewer resources and limited Medicare revenue, one provision in the law exempted doctors who treated a minimal number of Medicare patients. But CMS’s initial interpretation of this provision would have required all providers to collect and submit a full year’s worth of data in order to demonstrate they fell below the exemption threshold. This meant exempt doctors would still have to comply with all the program’s requirements, including updating their systems and reporting data, only to be excused from all this at a later date. It’s not hard to see why this approach, while technically accurate, would have worked against the intent of lawmakers. Those doctors would have left the program, hurting the very patients the law meant to help.

Another provision allowed smaller practices to form “virtual groups” to gain advantages enjoyed by larger practices. Staff interpreted this provision as a mandate to create a “Facebook for Doctors,” a platform for doctors to find and connect with each other. A staffer on loan from the United States Digital Service, a part of the White House, doubted that Congress intended for CMS to create a social media platform, especially considering the limited time and resources available. She took the almost unheard of step of consulting the House Office of the Legislative Counsel, and confirmed that Congress simply wanted to make it easier for small practices to report together and had no intention of mandating a “Facebook for Doctors.”

Under more common circumstances, these and other overly literal interpretations of the law would have resulted in a burdensome, unwieldy, and ultimately unsuccessful implementation. Doctors would have simply opted out, leaving patients with fewer options, and some in rural areas with none.

Thanks to nimble actions by people at CMS and USDS to ensure that Congressional intent was realized rather than over-relying on literal interpretations, this outcome was avoided. But conflicts like these all too rarely resolve in favor of common sense. Agency staff are commonly taught to treat legal language as literal operating instructions, as if a programmer had written code and they were the computer executing that code. But as any programmer will tell you, code rarely works as intended on the first try. It works after trying one approach, testing it, adjusting, and continuing that cycle over and over again. That cycle of adjustment is very difficult to engineer within policy implementation today.

We run on an open loop, in which implementation teams neither test their programs in the real world nor loop back to the source for adjustments. We need to build the affordances for them to do both, thus closing the loop. Otherwise, the code will more often than not run exactly as Congress wrote it, even if that doesn’t result in what Congress wanted.

This is emblematic of the problem and also insane: a government-created Facebook alternative for doctors for the express purpose of dealing with a procedural nightmare created by a well-intentioned but completely untested, unproven, almost certainly unhelpful, and very gameable quality goals.

 

The Necessity of Internal Moonlighting

03.02.25 // Radiology

I’ve been advising a radiology app startup called LnQ. I think of it like Qgenda for radiology moonlighting. It can link up with your practice schedule and HL7 feed and helps groups/hospitals/etc leverage the excess capacity in their own workforce: a practice can activate LnQ when there is extra work to do and automate telling the people who aren’t currently working when additional work is available, how much work is available, and then allow those people to do that work and get paid quickly for doing it without the multiple manual steps those processes usually require. It was first developed by an independent private practice that was struggling with their lists; since implementation, they were able to not only clear the lists every day but were able to go after some lucrative contracts knowing they had more bandwidth than they’d initially thought.

I think it’s neat, and I think it fulfills a need that many practices have. On top of its purpose of facilitating internal moonlighting, LnQ is also building a network of independent contractor radiologists on the app platform so that LnQ can also be used to directly connect individual rads and groups together without a teleradiology company or locums middleman adding friction and heavy costs. A practice can then notify their ICs when there is work available and at what rate. One of the issues I’ve discussed with practices multiple times since starting Independent Radiology is that many of them could use an IC here or there but not with enough frequency and volume that makes the ongoing hassle worth it for either party. LnQ is taking care of some of the initial vetting, and multiple practices on the platform will mean that everyone has a better chance of cobbling together the excess work and excess labor in one place to help everyone get the patient care done (of course credentialing will still suck until someone fixes that broken system).

If you are a group who wants to hear more or an individual rad looking for contractor work, you can see more here (the direct physician interest form is here).

//

When I first joined my practice in 2018, they’d already realized the importance of leveraging their workforce’s extra capacity so that when volumes were high, excess work could go to those with the energy and time to do it. Back then, however, we used to submit our after-hours cases as an Excel file attachment sent to payroll. It was tedious and prone to mistakes.

Flash forward several years later, and we have a full-time data analytics and computer dude who has built out workflows and internal apps to facilitate submitting reimbursement for expenses, paying for tumor boards and conferences, and essentially automating most of the tracking for our internal moonlighting from our worklist (Clario) database. Our moonlighting is per-click, and we know exactly which cases are being submitted for “after hours.” Our process is easy and fully transparent. We can run whatever analytics we want on it. For marking qualifying work, we’ve done things like mark the cases in Clario that are eligible (After Hours) or just used a list volume watermark, but the underlying principle is—when it comes to asking for help or providing help—friction is the enemy.

The reality is that with growing volumes and this volatile tight job market, recruitment isn’t always enough. And while, on the whole, the radiologist workforce is aging and burnout runs deep, we need to enable those with some juice left to squeeze more options so that those who have some bandwidth to trade time for money have the chance to do so in as many ways as possible.

Many practices have internal sales of call shifts or various swing shifts that are offered up as moonlighting, and if that’s enough to make everyone happy and get the work done? Great, you’re done. But even then…how much are those shifts paid? Does the rate get sweetened if no one wants to do them? How is that extra work tracked? Who does your payroll and how often do they mess up? How much time and effort does all of that take to coordinate? If no one is biting, can you offer up that shift to a contractor?

And, if extra shifts aren’t sufficient or desirable, that’s when ad hoc moonlighting on an hourly, RVU, or flat per-modality basis can become critical. A rad might have time for an extra scan here or there after the kids go to bed or be willing to work for an extra hour before or after their shift on occasion to avoid traffic but not be willing to commit to selling a vacation day or taking a complete extra shift or call weekend.

Taking it a step further, there are so many ways practices are structured to get the work done. Yes, a big practice with all work combined in one massive worklist and lots of overlapping shifts can make certain kinds of coverage very straightforward, but many practices have different kinds of work and multiple different systems to get it done. Is there a way you can choose to decompress a terrible call shift by asking others for a smidge of help?

What many practices need is a way to tell people who aren’t already scheduled to be working that there is work available to do, what/how much work there is (an hour? 7 RVUs?), and how much that work will pay. Maybe that payment amount changes or maybe it’s fixed. One thing you definitely don’t want is an uneven burden of easy or hard shifts disproportionately falling on certain individuals and be stuck with no way to make things fair. What do you do, for example, in a practice with multiple lists if some service lines are overly busy and those rads are stuck staying late to clear the hospital when other folks could just hop on sometimes and in a few minutes clear the list so everyone can go home on time?

Also for burnout mitigation, maybe someone who hates taking call wants to offer up some of their call pay to get some help or maybe it’s the practice just trying to get the work done when the number of warm bodies on the schedule isn’t enough without garnishing time off. Sometimes you can be a little more flexible on PTO or backup coverage if there’s an easy way to spread the work across willing people PRN.

Our group invested time and money into making a custom in-house solution that works for our practice (and, unsurprisingly, it doesn’t do all the things a dedicated company like LnQ has made possible; it’s a startup, so they can also easily add features as groups request them). Not all groups can or should bother creating a complicated tech solution to enable them to leverage their own workforce even if they do ultimately do need to leverage their own workforce.

Part of retention is meeting people where they are, and internal moonlighting is often one of those measures that can make both the slow vs fast and the lifestyle vs hungry readers happy. What more groups need to make the enterprise work is a system that makes it easy to tell the people who could potentially work extra when extra work is available, how much work is available, what kind of work is available, and then allow those people to do that work and get paid quickly for doing it without issues of tracking the work and other hassles.

We need more happy rads.

The ABR’s New EULA

02.25.25 // Radiology

Back in 2020, the American Board of Radiology released new agreements in order to participate in maintenance of certification “continuing” certification, the thing you have to do in order to be board-certified and practice radiology no matter how meaningless the process is (thankfully, the ABR’s OLA process is relatively painless). Back then, there was a bit of drama because they were draconian and frankly a bit sketchy. I wrote about it here.

In case anyone is wondering, the new version folks are signing this year again reads like the legalese you ignore when trying to install iTunes.

Just a few highlights to illustrate the degree of needless bullshit at play (Needless ALL CAPs is all them):

UNDER NO CIRCUMSTANCES, INCLUDING BUT NOT LIMITED TO NEGLIGENCE, SHALL THE BOARD BE LIABLE FOR ANY SPECIAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM INCORRECT INFORMATION PROVIDED BY THE BOARD TO THE MEDICAL COMMUNITY OR TO THE PUBLIC REGARDING THE STATUS OF MY CERTIFICATION, EVEN IF THE BOARD HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. APPLICABLE LAW MAY NOT ALLOW THE LIMITATION OR EXCLUSION OF LIABILITY OR INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO ME. I FURTHER AGREE THAT I WILL PROMPTLY NOTIFY THE BOARD OF ANY ERRORS OR OMISSIONS IN MY INFORMATION.

Under no circumstances is the ABR legally responsible for doing its core purpose.

The hedging of true radiologists:

THE CONTENT AND THE SITE ARE PROVIDED “AS IS” AND “AS AVAILABLE” WITHOUT WARRANTIES OF ANY KIND EITHER EXPRESS OR IMPLIED. TO THE FULLEST EXTENT PERMISSIBLE UNDER APPLICABLE LAW, THE ABR DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF AVAILABILITY OF THE SERVICE, NONDISRUPTION, SECURITY, ACCURACY, THE USE OF REASONABLE CARE AND SKILL, QUALITY, MERCHANTABILITY, TITLE OR ENTITLEMENT, FITNESS FOR A PARTICULAR PURPOSE, ABILITY TO ACHIEVE A PARTICULAR RESULT OR FUNCTIONALITY, AND NONINFRINGEMENT OF THIRD-PARTY RIGHTS, AS WELL AS WARRANTIES ARISING BY USAGE OF TRADE, COURSE OF DEALING, AND COURSE OF PERFORMANCE ON THE PART OF THE ABR, RELATING TO THE SITE AND THE CONTENT. THE ABR DOES NOT WARRANT THAT THE FUNCTIONS OF THE SITE OR THE CONTENT WILL BE UNINTERRUPTED OR ERROR-FREE, THAT DEFECTS WILL BE CORRECTED, OR THAT THE SITE OR THE SERVER(S) THAT MAKES THE SITE AVAILABLE ARE FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS. ACCESS TO THE SITE MAY BE SUSPENDED TEMPORARILY AND WITHOUT NOTICE IN THE CASE OF SYSTEM FAILURE, MAINTENANCE, OR REPAIR, OR FOR ANY OTHER CAUSE. APPLICABLE LAW MAY NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, SO THE ABOVE EXCLUSION MAY NOT APPLY TO ME.

I’m sure this is all normal. And just a final catchall disclaiming liability for anything and everything:

THE BOARD SHALL NOT BE LIABLE FOR ANY DAMAGES OF ANY NATURE SUFFERED BY ANY CUSTOMER, USER, OR ANY THIRD PARTY RESULTING IN WHOLE OR IN PART FROM THE BOARD’S EXERCISE OF ITS RIGHTS UNDER THIS CONTINUING CERTIFICATION AGREEMENT.

I posted the corresponding screenshots on Twitter of the site pop-up that you are forced to sign; the agreement is not available on a public-facing URL. Not included in the above, among other things, is the part where they also explain that they will never identify anyone who reports you to the board so that you could better defend yourself against allegations.

Do lawyers correlate clinically?

The Fool’s Errand of 30-year Radiology Predictions

02.24.25 // Radiology

From a Radiology Business summary of two new JACR papers predicting the future radiology market:

In the next 30 years, the supply of radiologists is expected to grow by nearly 26%, assuming no increases in the number of radiology residents. Meanwhile, imaging utilization will climb between 17-27% during the same time, depending on modality, experts detailed in the JACR.

[…]

The present radiologist shortage is projected to persist unless steps are taken to grow the workforce and/or decrease per person imaging utilization…the shortage is not projected to get worse, nor will it likely improve in the next three decades, without effective action.

The two papers are here and here. To be fair, if you read the papers, there is more nuance to their predictions, and they acknowledge important trends (e.g. higher radiologist attrition in recent years and increasing utilization rates even outside of aging/demographic trends) that could easily result in big differences.

But.

Does anyone think taking any version of the current status quo of either the radiology workforce and current imaging volume trends and extrapolating 30 YEARS into the future generates a meaningful prediction?

Radiology was radically different 30 years ago and multiple predictions during that period were comically wrong. I don’t see a reason to assume the future will be any more predictable. A world where AI changes nothing and the already increasing role of non-radiologists in imaging interpretation (including but limited to midlevels) magically flatlines is not a world I think we live in.

A stable 30-year workforce shortage would be…impressive.

Choosing Rocks

02.20.25 // Miscellany

There’s a common first-things-first productivity parable of the rocks and the jar. It goes like this:

Imagine you have an empty jar that represents your life, and you have different sizes of rocks that represent different priorities and commitments. The big rocks represent the most important things in life, like your family and health. Medium rocks would be secondary priorities like intermediate career goals, social commitments—other worthwhile but less crucial activities. And finally, the small rocks and sand represent the minor daily tasks, distractions, and time-fillers that can easily consume our attention.

The thrust: If you fill your jar with sand and small rocks first, you won’t have room for the big rocks. But if you put the big rocks in first, then the medium rocks, the sand will filter down into the spaces between them—and everything fits.

From Oliver Burkeman’s Four Thousand Weeks: Time Management for Mortals:

Here the story ends—but it’s a lie. The smug teacher is being dishonest. He has rigged his demonstration by bringing only a few big rocks into the classroom, knowing they’ll all fit into the jar. The real problem of time management today, though, isn’t that we’re bad at prioritizing the big rocks. It’s that there are too many rocks—and most of them are never making it anywhere near that jar. The critical question isn’t how to differentiate between activities that matter and those that don’t, but what to do when far too many things feel at least somewhat important, and therefore arguably qualify as big rocks.

That tracks.

The Art of Creative Neglect Principle number one is to pay yourself first when it comes to time. I’m borrowing this phrasing from the graphic novelist and creativity coach Jessica Abel, who borrowed it in turn from the world of personal finance, where it’s long been an article of faith because it works.

Abel saw that her only viable option was to claim time instead—to just start drawing, for an hour or two, every day, and to accept the consequences, even if those included neglecting other activities she sincerely valued. “If you don’t save a bit of your time for you, now, out of every week,” as she puts it, “there is no moment in the future when you’ll magically be done with everything and have loads of free time.”

From both of these passages, my takeaway is that we can’t hope it actually choose all the rocks in some cohesive way. Avoid some of the useless filler sand, sure. But, maybe, don’t wait and just choose a rock sometimes:

Thinking in terms of “paying yourself first” transforms these one-off tips into a philosophy of life, at the core of which lies this simple insight: if you plan to spend some of your four thousand weeks doing what matters most to you, then at some point you’re just going to have to start doing it.

The easy trap is the too many coals in the fire:

The second principle is to limit your work in progress. Perhaps the most appealing way to resist the truth about your finite time is to initiate a large number of projects at once; that way, you get to feel as though you’re keeping plenty of irons in the fire and making progress on all fronts. Instead, what usually ends up happening is that you make progress on no fronts—because each time a project starts to feel difficult, or frightening, or boring, you can bounce off to a different one instead. You get to preserve your sense of being in control of things, but at the cost of never finishing anything important.

I’m trying to work through a backlog of abandoned work, but at this point my inability to focus, attend, and limit possibilities is a core character flaw.

Quality, speed, and “productivity”

02.17.25 // Radiology

The Tension

There is an inherent tension in radiology between quality and speed. Obviously, there are faster radiologists and slower radiologists. And there are better radiologists and worse radiologists. It is not even that you are either fast or slow in all contexts. It is also not a false dichotomy in that you are either slow but good or fast but bad. Everyone exists on a continuum for both.

In general, an individual will experience a decrease in quality past a certain increase in speed, which may be compounded by case mix, complexity, time of day, and number of interruptions. But also: we are unlikely to realize meaningful gains in quality past a certain decrease in speed. You only need so much time reviewing a study before experiencing diminishing returns.

The Incentives

Because groups are comprised of individuals, and individuals fall on a spectrum, it is challenging for a group to incentivize everyone to perform at their optimal point on their speed/quality curve. For one thing, some people, when incentivized in a productivity system, are perfectly willing to churn out garbage if it earns them more money. However, in a completely flat structure where everyone earns the same regardless of the number of work units produced, there is also no incentive for individuals to work hard if their natural pace would lead them past a predetermined watermark. A fast reader has the perverse incentive to slow down and watch streaming video instead of continuing to crank while a slowpoke in the cubicle across town is agonizing about sub-grading neural foraminal stenoses and measuring nonactionable cysts or something else in their report with at most borderline helpful, exhaustive detail.

What is “fair” and how do we achieve it?

A small practice may recruit such that personalities mesh across all partners and democracy works without much effort. Everybody knows everybody. Everybody is accountable to everybody. Everybody puts in the work lest they be publicly shamed or ostracized or simply because it’s part of being on a team. If there is a productivity component, then ideally everybody is equally interested in putting up numbers and making lots of money. It explains why some small groups can be so successful.

Conversely, a larger practice may resort to relatively strict productivity, controls, and incentives because social dynamics play less of a role.

When you are creating a large machine full of cogs, what’s easiest to measure (and to some also most important) is how many widgets that machine can produce. Especially if quality is secondary—and clearly some outfits believe it is—it’s just so much easier, trackable, and profitable to incentivize volume.

And if your practice is designed for maximum profitability—doubly so if that practice requires that profitability in order to meet shareholder expectations or service large debt obligations—then it’s not hard to see how that becomes the dominant paradigm.

The Complications

Where things become more complicated are in medium and large independent practices and academics. These larger groups often used to be smaller groups and they had a legacy culture that may or may not have become diluted or strained with the growth and/or consolidation that many markets have seen over the past 15 years. Sharing the pie equally may have been an easy solution in old times but now increasingly becomes untenable in the setting of enlarging worklists, high volumes, delayed turnaround times, and difficulty recruiting.

Democracy may be desirable but that doesn’t make it easy.

You want a way to discourage loafing and shirking responsibilities but you also don’t want to promote negative behaviors that often arise from RVU-based performance. One big one that many groups face is cherry-picking. The other is a push away from important practice-building but non-remunerative tasks. If you are being paid extra to produce more numbers then why would you want to talk to a clinician on the phone if you could have read another scan during the same amount of time? Why would you want to read plain films or thyroid ultrasounds if there are screening mammograms or negative headache brain MRIs ripe for the taking? And—hardest to measure—quality.

The Solutions

There are ways to mitigate everything but no clear one-size-fits-all solution. There are trade-offs to all choices, and not all practices need complex systems to function. The practical reality is that when pursued these kinds of changes are hard, require much thought and buy-in, almost invariably involve infighting, and are probably best solved via IT solutions that streamline workflows, prevent individually negative behavior, and potentially incorporate ways to reward all desired tasks—even when those don’t generate billable RVUs (e.g. automatic case assignment ± customized internal RVUs to better account for effort ± “work” RVUs for nonbillable tasks). As former Intel CEO Andy Grove said: “Not all problems have a technological answer, but when they do, that is the more lasting solution.”

But it’s not easy, and it requires deliberate choices and strong solutions. An ideal practice doesn’t build itself.

The Procedure Fetish / Bureaucratic Anxiety Cycle

02.13.25 // Miscellany

From “The how we need now: A capacity agenda for 2025 and beyond,” published by the Niskanen Center think tank.

What are the forces making the government so slow? The first of those dysfunctions is what Nicholas Bagley of the University of Michigan calls the “procedure fetish,” and we dub the bureaucratic anxiety cycle. Anxiety about legitimacy and accountability drives critics to demand, and bureaucrats to seek refuge behind, more and more layers of procedure that show things have been done “by the book.” But all that procedure further erodes both legitimacy and accountability by overburdening the bureaucracy, reducing its ability to deliver meaningful outcomes.

In the addition to the government, tell me this doesn’t summarize every large company you’ve ever dealt with, especially any that deal in a high-regulation industry like healthcare.

They go on to flesh out the “Cascade of Rigidity” with a helpful infographic:

Well-intentioned laws and regulations become increasingly inflexible and counterproductive as they evolve toward implementation. The authors argue part of the solution is shifting focus:

The revised system must shift its emphasis from compliance to meeting mission needs. This means power to make decisions must shift from compliance personnel to the people closest to the work.

The vicious cycle of growing bureaucracy and procedural bloat requires a reversion to our ultimate goals: a need to serve the mission and not its own machinery.

“This means power to make decisions must shift from compliance personnel to the people closest to the work.”

No easy feat.

“Only the paranoid survive”

02.10.25 // Miscellany

Old advice from Andy Grove, former CEO of Intel (back when Intel was killing it), from a 2007 Esquire interview:

Not all problems have a technological answer, but when they do, that is the more lasting solution.

The problem, as anyone who has used an EHR or any other enterprise software, is that the problem being solved (e.g. optimal billing) may itself create a wealth of downstream problems (e.g. frustrating, inefficient healthcare).

Satisfaction doesn’t come in moments but in periods of time.

Beware the arrival fallacy.

Success breeds complacency. Complacency breeds failure. Only the paranoid survive.

This is ironic in that post-Grove Intel entirely missed the boat on mobile an increasing fraction of everyone’s devices utilize the ARM architecture.

It’s also so painfully clear that this manifests in the lack of institutional and cultural knowledge that plagues schools, organizations, and the government. We rest on the status quo when it works until it doesn’t.

But the problems compound when we then forget the parts that got us there in the first place in our desire for improvement.

Sometimes inefficiency is a critical piece of the puzzle (like we saw with Covid supply chain issues). Other times, we are unaware of the lessons from the past and miss the negative externalities of our panicked interventions.

Profits are the lifeblood of enterprise. Don’t let anyone tell you different.

We have to live in the world as it is.

There’s never enough time.

True and true.

If private practice is so great…

02.03.25 // Radiology

Since I started writing about private equity in radiology back in 2022 and more recently since featuring private practice jobs on the site followed by launching Independent Radiology, I often get questions that read something like this:

If private practice is so great, why are so many groups struggling?

Because it’s hard.

I believe that private practice is important. It provides an anchor for how doctors are paid and establishes standards for how a specialty chooses to practice. When employed positions are good, that is largely a direct result of the need to compete with private practice in a tight labor market.

However, it does not necessarily follow that all or even most practices are run well. It was relatively easy (I imagine) to run a business during the golden age of radiology; it isn’t easy now. And we should admit, without hesitation, that of course there are also poorly-run unsavvy groups just like we’ve all experienced poorly run hospitals and other businesses.

It’s also much easier to run an effective business when it’s a small democratic group where everyone has skin in the game and the desire to make it work. Increasing imaging volumes and increasing consolidation combined with increasing regulatory burdens and have resulted in overall fewer and overall larger groups. That increases the stakes and increases the complexity. The growing pains are real.

Instability is Everywhere

I do think the current shortage, shifting lifestyle demands, and the (probably temporary) sweetheart deals for mammo ultimately have destabilized radiology practice in general, not limited to but certainly including small democratic practices where radiologists wanted to be treated the same historically. (As in, a young breast imager’s desire for shorter workweeks of 100% breast without any evenings or call doesn’t easily jive with how many practices have historically practiced, and the need to play ball to recruit sometimes requires substantial chances to practice structure with negative downstream consequences). I think the shortage has absolutely shredded some democratic groups, especially those that are small with a lot of physical presence, call, or struggling to staff women’s imaging.

Everything is Local

The reality is that the success of any given model is in part predicated on regional dynamics. If the hospitals don’t have to play ball in tough group negotiations, it’s hard for groups to get what they need for retention and recruitment in the current climate. Stipends are increasingly table stakes to cover off-hours and on-site work in an era where direct reimbursement is falling and labor supply is insufficient. We aren’t a free market in medicine because we don’t control how much we charge. In a normal labor market, a labor shortage will drive up compensation. That needs to happen here too, but that money has to come from somewhere when it can’t happen organically from CMS or the commercial payors in our fee-for-service model.

Hospitals have the ability to supplement compensation with a fraction of technical fees and stipends, which means that–if they want to–they can (potentially temporarily) offer more money and potentially even a “better” job than a group relying on professional fees alone. They could give that support to a private practice so that the group is healthy, or if they are more daring, they can be aggressive and use that as leverage to bring the group in-house. In the short term, I imagine the downsides of employment for radiologists are probably pretty small right now. The market is so tight they can’t play too many games or risk the whole thing blowing up. Longer term, I am more skeptical.

The Tele Problem

One thing that gets lost in the generally increasing hospital stipend support trend and more remote work: some hospitals in less affluent areas will struggle to pay higher rates and may be hard-pressed to provide stipends needed to account for competitive compensation in the current market or high levels of bad debt from unfunded patients. Some areas are geographically undesirable, adding another wrinkle to any efforts at recruitment. If you can’t recruit to the area because no one wants to live there, then you need to pay for remote rads. But the market for remote rads is increasingly national, not local. Which means you need to be able to compete nationally.

The more people who want to do teleradiology, the more groups struggle to sustainably get the work done locally. So we can just say it: people’s individual desires are destabilizing the field. It may be reasonable for the individual and their family but no doubt it’s a growing problem for local high-touch practices. It also makes it easier for rads to quit their jobs for any reason and find work without having to make geographic changes. Lower friction means mobility, which means more volatility and churn.

But it’s essentially a tragedy of the commons situation. If everyone wants to work from home sometimes, no big deal. But if too many people want to work remotely too quickly, it’s hard for the industry to quickly accommodate and it destabilizes everyone’s work.

Note that instability here isn’t necessarily bad long term, it could even lead to long-lasting improvements in some domains. But, increased volatility and drama are inarguably close bedfellows with the current tele trend.

Could most radiologists give up contrast coverage, basically refuse to do the vast majority of fluoro of any kind, and be 100% remote? In some practice settings, probably. But the downstream long-term consequences of too much of the field going that way is to throw open the doors to replacement. The faster we consider practicing radiology only to mean interpreting imaging, the less real clout we have.

Consolidation is Real

One factor that does matter is size. Larger groups servicing a larger part of a large client are harder to replace, tend to be able to provide more remote work options, have dedicated nightfolks/less call, etc. A fragmented market with many small groups in the current era of big consolidated health networks, payer shenanigans, CMS cuts, and stupid MIPS compliance measures is less predictable than one with a few big groups that are busy enough that they really aren’t competing with each other so much as holding a line against the hospitals. These jobs aren’t always better. The groups may be culturally diluted and overall indistinguishable structurally from any other medium to large company. But, they may be more stable when faced with headwinds.

Ultimately, radiology is still a human enterprise. Relationships matter. Hospital leadership, radiologist leadership, other clinicians, the patients–they matter. So I do think it’s critical that no one should take an overall trend facing our field with a prediction for any specific group. There are thriving small groups that are killing it.

Macro trends are easy to opine about as a random person on the internet. But real life is lived in the details.

Risks & Opportunities

A staffing shortage climate nationwide is only an opportunity because it’s also a risk. The increasing complexity of regulation coupled with needing to work with increasingly consolidated revenue- and growth-focused mega health systems and fight large payors increases the stakes and bureaucracy of running a practice. And that can be especially hard when recruitment and retention are intrinsically unstable as everyone starts working harder than they want to.

There is a zero-sum recruiting component to the whole radiology enterprise where some companies with better contracts are able to at least temporarily offer better jobs on paper with more flexibility in order to handle their overflow or fuel their growth in remote coverage. Look no further than the recent United and Aetna lawsuits against Radiology Partners to see how one really great contract can provide the temptation to double down on arbitrage as the core business model (even in cases where it might be…illegal).

Dominoes are falling–and that means opportunity for others–but all that opportunity only exists because some practices are failing or falling behind or dropping contracts–and hospitals are desperate. For every group that comes in and sweeps up by landing some great contract, it means that someone else has downsized, failed, and/or some hospital was recalcitrant in how they approached an important negotiation. Even when everything works out well, it means there’s a lot of stress and conflict in the process.

In summary, I think a large part of the instability really has less to do with the practice model itself and much more to do with staffing shortages more broadly.

The reality:

I don’t think this is a simple time to be a radiologist or to run a practice, but I think the real existential difference between private practice and other models is that the hospital can get locums or pay extra for a different group if they are forced to, but an independent practice fails when it fails. There is no alternative: it either works or it doesn’t.

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