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?

The battle between Radiology Partners and UnitedHealthcare has ended with United as the victor.

The summary:

• RP claimed United owed them lots of money for underpayment because United was using a 2020 contract to determine some of its payments instead of a more lucrative 1998 contract originally held by one of its purchased groups, Singleton.
• United then sued Radiology Partners alleging an illegal pass-through billing scheme. It’s a good read.
• The arbitration panel awarded RP an interim award of $153 million. This was very much interim, not just because the independent panel had awkward bias conflicts, but also because the panel decided to separate the question of whether Singleton’s lucrative contract was in effect (it was) and if RP was abusing it (which it was) into separate steps.

The $153 million award would really have only been an extra $94 million since United had already paid for the work at a lower rate. (Author’s note: That’s quite the contract.)

Phase III–that awkward fraud question–just finished. The ultimate findings of the panel (free login required):

In the Phase I Decision entered on April 2, 2023, the Panel made the following finding: “The Panel finds the 1998 contract to be the operative agreement between the parties.” The Panel confirms this finding.

In Phase II the Panel entered the Interim Award On Singleton’s Arbitration Demand on September 26, 2023. The Panel now vacates that Interim Award.

The difference between the amount United paid on claims pursuant to the rates specified in the 2020 Agreement and the amount it would have paid pursuant to the rates specified in the 1998 Agreement is $94,275,324.00. United’s underpayment of Singleton’s claims at the rate specified in the 2020 Agreement was a breach of the 1998 Agreement.

Because of its breaches of the 1998 Agreement and its other acts and omissions, Singleton is not entitled to recover this difference and underpayment or any other relief against United. Because of its breaches of the 1998 Agreement and its other acts and omissions, United is not entitled to any other relief against Singleton. The Panel determines that the evidence fully supports these decisions at law and in equity.

Translation: you are both jerks, you are both wrong in your typical unique and despicable ways, please go away forever:

United was wrong to unilaterally use the incorrect contract to determine payments. RP was wrong to hide its ownership and then essentially pretend that every group in the region it owns was Singleton when they clearly weren’t.

(For more description/backstory, see the previous two posts: United against Radiology Partners & United is Still Fighting Radiology Partners.)

For those keeping score at home, United’s lawyer was correct when they said, “We do not agree that Singleton will recover an award from UnitedHealthcare.”

In other news, whether or not they were right, United is still a terrible company.

Something happened to the field of Radiology.

Actually, a lot of things have happened and are happening to Radiology all the time, but one of those things has been that the proliferation of corporate and private equity-backed radiology practices over the past decade has been followed by a historic radiologist shortage, a subsequent piping-hot radiology job market, and a challenging zero-sum game to hire on-site and even remote radiologists.

There are thousands of rad jobs available in the country and more work than the field can handle, but only a fraction of those positions are at independent radiologist-owned and controlled private practices. A lot are not.

That’s why I’ve temporarily been posting a radiology job ad on this otherwise very personal site, and that’s why I’ve just launched Independent Radiology.

From the “Why?” page:

The thriving independent private practice of radiology is critical to the future of the field. True private practice–where doctors control the organization, are responsible to their peers and patients, and earn the full fruits of their labor–is the benchmark that sets the market and provides the anchor against exploitation from unscrupulous employers.

This site exists to help those radiologists looking for the real deal.

You don’t have to agree with me, and you also don’t have to care. Not everyone needs or wants to work in private practice, and of course that’s fine. I also believe in the academic mission, and there’s nothing inherently wrong with being an employee. I also don’t want to just glamorize a practice model. Models aren’t destiny, and a private practice isn’t necessarily a good practice.

But, I do believe every radiologist should hope for the success of independent radiologist-owned private practices. The ability to join a thriving independent practice where doctors get paid for the full amount of their professional work and have the autonomy to choose how to do it is what forces employers to compete. It’s the anchor. It’s the BATNA that every hospital and corporate suit knows you have. It’s what keeps them honest.

By another analogy, the employment model is the renting to a partnership’s buying. There’s nothing wrong with renting. Renting can be great! Sometimes, based on your finances, the available options, and the local factors, renting is simply a better, safer option than buying. It’s undeniable. Not every house is a good purchase. And, when you have a good landlord, who charges you a fair market rate and is quick to fix the things that break down, renting can be an easy low-friction experience.

But we are stronger as a field when ownership is a real possibility. And, like homeownership, when you buy a good property, in the long run, you generally end up ahead. You have to deal with some upfront costs and the upkeep–oh, the upkeep!–but you also have more say about the property and you’re not reliant on someone else’s goodwill or business savvy. You have a good place to live: a home, not just a house. For the renter, the landlord can always change. They can always call your bluff and see how far they can push you before you decide to move. That’s why viable options are important for the whole market.

So, I wanted to make some space online to help those who want to join and help build a practice to find what they’re looking for. And, I wanted to build a place to showcase true independent radiologist-owned private practices in order to help them find radiologists in this challenging market.

I hope it’s helpful.

Here’s a little compilation of posts from the last few years about getting started as a new radiology resident.

Doing

Approaching the Radiology R1 Year and its short companion post: How to be a First-Year Radiology Resident.

Want something a little more controversial? You Should be Correlating Clinically.

Learning

Book Recommendations for First-Year Radiology Residents (and some further recommendations for when there’s extra book fund to burn).

You can round that out with some more general thoughts on studying during residency. Then try my deeper dive: ultralearning radiology.

Also, residents from across the country in the ACR Resident and Fellow Section came together and assembled a nice collection of free radiology learning resources from across the interwebs including lots of videos.

Should new residents worry about workflow efficiency and ergonomics?

Yes.

I don’t think it’s ever too early to start thinking deliberately about what makes you better and more efficient in your job or able to act more sustainably. If anything, spending more time on workflow and ergonomics early on in your career is an investment in yourself.

As a resident, I just used whatever was plugged into the workstation I sat at. This eventually led to wrist pain, which even more eventually led me to finally address my setup as an attending. The physical discomfort became obvious. The hit on my productivity/efficiency for all those years was invisible until I made the changes.

Many people, especially once out in practice, become entrenched in their behavior patterns and find it very difficult (and even frankly overwhelming) to approach changing how they work, even when the change is clearly beneficial.

I would say, on a practical level, that it may take some time after starting residency to know exactly what your needs are, what you like and don’t like about the default approach, and what an ideal workflow may be. But taking the basic step of buying a good mouse and programming it to help use PACS is an approachable and very helpful first step. At least do that, and then you can decide if you need to go down the rabbit hole.

The Approach

In general, you will find things easier especially as a resident if you can have a setup that requires no on-site software/driver installation, given the realities of bouncing around multiple workstations and the difficulties of working with your local IT department. Devices that can store their own settings and function plug-and-play on any computer are often described as having onboard memory.

I think a reasonable approach early on would at least involve some kind of gaming or productivity mouse to store window-level settings and your favorite PACS tools.

As you can see if you dive into my multi-post series, I personally divide these tasks between a left-hand device and a right-hand device and also incorporate dictation controls with Autohotkey. I think this is the optimal approach (and one that some of my residents have even now begun using). A dictaphone-free approach however really does require AutoHotkey to work efficiently, so utilizing this would depend on if you are able to get the executable file onto a workstation in order to run your shortcuts (or if the thing is locked down so tight that you won’t be able to). You may not know until you try or talk to someone local who has.

So, if you decide to take the streamlined approach and try to put all the PACS tools you want on a single device, you may find it helpful to have something with a large number of configurable buttons. A good example would be the reasonably priced UtechSmart VenusPro (a 16-button wireless mouse that includes a 12-button thumb grid). The G604 Lightspeed would be another popular choice (more expensive, adjustable scroll wheel, 6 thumb buttons). I personally use a “vertical” mouse, and I discuss even more mouse options (and everything else) at length in my “best stuff” post. (My hospital mouse is the very inexpensive Zelotes–which I describe how I use here–but it won’t be for everyone.)

Unless your radiology department is more forward-thinking and responsive than most, whatever is plugged into your computer is unlikely to be a good mouse for utilizing PACS. Even if it is, it probably isn’t configured the way you want, so literally any variety of productivity or gaming mouse that you customize yourself will provide some obvious and immediate benefits. The ultimate goal is that you should not need to move your hand off your mouse (or put down your microphone) in order to use a keyboard for routine actions.

If you need to touch the keyboard for every case, I would say you’re doing it wrong.

How Many Buttons Do I Really Need?

Good question. Everyone is different.

Some potentially very helpful shortcuts will vary a little by how your PACS handles measurements and things like zoom/pan. Some PACS automatically incorporate a manipulation tool like zooming into the central mouse wheel click or holding left/right mouse buttons simultaneously, whereas others require a keyboard shortcut. Some PACS will automatically helpfully change what the right click does depending on which PACS tool is active. Others do not. Some PACS delete measurements by double-clicking, and some make you press the delete key. That’s why it can be challenging to completely figure out what you want without some trial and error and becoming familiar with your local enterprise software function.

But here is one version:

Four window/level presets are probably sufficient for most people’s needs (e.g. soft tissue, lung, bone + brain or liver or your fourth favorite).

Some common choices for mouse button shortcuts are the measure tool, the ROI tool, delete, localizer/3D cursor to cross-register findings, and whatever button you need to turn back on power scrolling. Again, the exact details vary by PACS. That’s ~five more.

Most people would find the angle tool or spine labeling to be less important, but obviously in some cases those are in constant use, etc. Some PACS have a dedicated toggleable navigation pane to see priors and image series.

Add those together (~12) and it’s not hard to see how one can go crazy and fill up the thumb grid on one of these mice with all tools you need, even if you aren’t trying to add toggling dictation + previous/next template fields as well (3 more).

I will admit that it can be hard to retain all of these in muscle memory, which is one reason why I like using both hands. I suspect a lot of residents are already learning so much and doing so many new things that a smaller number of inputs may be more likely to fall in the sweet spot of being helpful without being overwhelming–but if you’re willing to put the time and energy in, you can get a ton of mileage from a high-button mouse.

Regardless, there is no world where you wouldn’t rather at least change your window/level settings from your mouse instead of dropping your mouse to hit the numpad on your keyboard instead.

Ultimately, the more things become easy for you to do, the more frustrating it is when some task requires you to break your flow.

Take Home

I’m not suggesting you should go full nerd mode and spend a bunch of money.

But, yes, you should at least get a programmable mouse for work.