The American College of Radiology runs a large and presumably quite profitable job forum. (I believe they outsource its management to a third-party company, but it’s on their website, and their branding is all over it.)

And I’m sure the ACR doesn’t want to police the content of that job forum, if nothing else because nitpicking job listings may discourage people from paying for said listings. Outside of the logistics and hassle, there is an obvious financial incentive to look the other way to potentially misleading content.

However.

I don’t see how one can justify allowing Radiology Partners to disingenuously call itself an “independent private practice” on its job postings (other than by just acknowledging the financial conflict that RP is probably the job forum’s largest customer by a wide margin).

I’m not even saying these are bad jobs. Quality is irrelevant here. You are what you are, and pretending you’re not a nationwide private equity conglomerative corporate practice in a job listing for a teleradiology position is only something you do because you don’t want to get filtered out of people’s search queries.

Here are the options for “work setting” they could have picked:

• Academic institution
• Independent private practice
• National radiology practice
• Health system or hospital
• Hospital-affiliated group practice
• Non-hospital group practice
• Multi-specialty entity
• Outpatient clinic
• Military Treatment Facility
• U.S. Public Health Service
• Department of Veterans Affairs facility
• Teleradiology
• Locum Tenens/Independent Contractor
• Other (Please specify)

If you believe in your model and are proud of your practice, then why pretend that you are independent when you’re not? Why not just pick “teleradiology” for a tele job? The straightforward explanation is that they know what job applicants want/are searching for, and their ads will perform better if that’s how they’re listed.

All the RP listings I’ve seen–and not just for the direct RP corporate offerings like this but also for their individual groups–describe the work setting as independent private practice.

This seems, at best, duplicitous and disingenuous. The generally accepted meaning of an independent practice is a business owned and operated entirely by its physicians (and not a hospital, health system, or other business/corporate entity). Physicians are the minority owners of Radiology Partners.

It doesn’t matter if one believes that independence or some variety of corporate structure is better (or even if they’re on the whole equal). There are multiple different options, and RP is cynically picking the wrong one.

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Meanwhile, a quick update about that non-independent parent corporate entity, as reported in Radiology Business this week:

S&P said it is placing all Rad Partners’ ratings on CreditWatch with negative implications. This reflects “heightened downside risk,” analysts noted, given the potential that RP might default on its loans or engage in a distressed exchange in 2024.

Update 1/11/2024:

The specific practice loan that I referenced as giving rise to this post began earlier in 2023, and this post was months in finalizing. I’d originally intended to publish it in the summer. Since publishing, I’ve since learned that RP’s extra support has briefly paused.

That’s right, at least for a month or two, the group’s compensation reached the threshold that turned off the “advance” from RP. Hospital subsidies saved the day. Note that the loan term itself isn’t over, and after briefly not needing it, the group has since required more gravy.

Ultimately, this suggests that RP may have chosen the loan method for supporting this practice because they had specific reasons to (correctly?) believe that the loan period would be time-limited: It’s obviously better to give some money temporarily in a non-binding fashion to save a group in crisis than to permanently change the contract if you don’t have to.

The real question for the future will be: will the group consistently earn enough in the end to pay back several million dollars of borrowed money, and if so, how long does that take? And/or, does the group fight it? It sounds like what  seemed like free money at the time may ultimately be an actual loan, and paying back that advance will therefore constrain compensation going forward unless long-term profits stay below the mark due to increased contractor use, the need to sweeten up internal moonlighting rates, or understaffing requires dropping volumes. Any or all of those things may happen. They are things happening at groups of all stripes across the country.

The future remains uncertain as always–and RP may still never recoup this loan–but this also means that I was wrong in how easily I dismissed the likelihood of RP seeing some of this money back.

This month credit agency Moody’s downgraded Radiology Partners again (surprising exactly no one): the first (and smallest) of its large debt obligations is due in 2024, they currently owe 10x their earnings, and they can only service these debt obligations through refinancing, which is challenging in the current market even before you consider the potentially tenous state of RP’s acquired practices when they reach their 5-year vesting window. It was inevitable.

If you ask RP, they will tell you that all third parties–whether Moody’s or just a random internet troll like myself–don’t understand their business and aren’t privy to the magic happening behind the scenes.

They consistently maintain that they will be able to refinance, though they never publically acknowledge that the most likely refinancing they will achieve is some form of distressed exchange like a debt-to-equity swap that would likely dilute current shareholders (and is considered a bankruptcy equivalent).

Here’s a slide from their big meeting earlier this year:

I know some people in the radiology community think that when the debts come due that RP will go bankrupt and disappear, but that’s simply not going to happen. Depending on how broadly one defines “success,” there’s an excellent chance they’ll be successful. (To wit, Envision emerged from bankruptcy in the hands of its creditors, but it didn’t go anywhere.)

But here is something you haven’t seen in the news but is nonetheless interesting:

Radiology Partners—already dealing with recurrent credit downgrades, cashflow problems, and investor fears—has been offering no-interest loans to some of its practices to shore up compensation.

Note: I’ve heard a similar story independently from several RP radiologists, but I do not know how common the offer has been (I suspect not very). For what it’s worth, I did reach out to RP and Melinda Collins (AVP of Marketing and Communications) on Twitter/X last week without a response. If you’re at RP and want to weigh in on this purported practice, please reach out. If I’m wrong or misleading in any way, I really, really want to know.

To my knowledge, nobody has pressed RP on this issue yet, and it has not been discussed in any public forum other than a brief mention on this site earlier this year in a quotation from a former RP radiologist. Since that time, I heard from multiple sources that at least one practice has taken the offer, hence this post.

So how does this look in practice? Let’s discuss.

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I wrote a long post with lots of options for the best personal radiology equipment (and additional posts about using a left-hand device or implementing the magic of AutoHotkey for achieving hands-free dictation and efficiency).

But gosh, all those words!

For the use-with-your-hands part, here are some quick contexts and a single choice for each that you can implement wherever you work:

Mouse:

• Wrist hurts + want magic buttons and/or can’t install software: Zelotes C18/TRELC
• Wrist hurts + normal buttons and/or can install software: MX Vertical
• No wrist pain + Goldilocks (good but not insane amount of magic buttons, on-board memory means no software needed at each computer): G604 Lightspeed
• No wrist pain + ludicrous number of buttons: UtechSmart VenusPro
• Debilitating wrist pain please help nothing is working: Roller Mouse

Off-hand:

• Left-hand device with buttons and scrolling behavior: Contour Shuttle Pro V2 (read more here, software required)
• Left-hand device with buttons and on-board memory: ELSRA Smart (cheap, labelable)
• If you’re adding an off-hand device, you’ll want something to hold the dictaphone near your face. A cheap clamp like this works great.

Note: I didn’t get into any of this stuff until I became an attending, but looking back, it is insane that I was just using the garbage plugged into the workstation wherever I sat down.

While not everyone wants or needs to go full-on mega nerd with a hands-free setup and a left-hand device (though it’s awesome and I kind of do think everybody should), even residents would benefit from at least an inexpensive gaming/productivity mouse, especially for call when speed matters (it’s also during those night float months that many of us first began to experience repetitive stress injuries from bad ergonomics and inefficient workflows.) Optimizing is a worthy investment of time/energy/money.

When I was serving as chair of the Texas Radiological Society’s Young Professional Section, I surveyed practicing radiologists about the transition between training and independent practice. This collection, along with other career advice, is collected on the YPS page of the TRS website.

Here are some highlights from their advice:
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With the recent advances in LLMs, I suspect dictation improvements are one of the things that will be increasingly available in the very very near term future (though how cost-effective those plugins or replacements will be remains to be seen).

In the meantime, PowerScribe is ubiquitous in radiology practices across the country, and it’s the only dictation software I use in my job. It has many flaws, but there are plenty of things we can do to make the most of it.

If you’ve been using PS for a while, you will likely be familiar with at least some of these features, but a lot of radiologists just use it like a stubbornly inaccurate transcriptionist.

Here are some tips for making PowerScribe (360) suck less:

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This post could have been titled:

• Why and How to Use an Offhand Device for Radiology

Or maybe even:

• How to Make the Most of All Those Extra Buttons on Your Gaming Mouse or Similar Device

We’ll be talking about using productivity devices to make diagnostic radiology more biomechanically (and functionally) efficient. I was personally more focused on the former (repetitive stress is no joke), but both are important. Even if you don’t want to read more cases per day, reading the same number of cases with less friction is still a win.

This discussion applies broadly, but we’ll be doing so through the example of my current left-hand device: The Contour Shuttle Pro V2, a weird little ambidextrous off-hand device mostly used by video editors:

The principles of optimizing your radiology workflow and customizing tools for manipulating PACS are nonspecific. Whether you use this device, some sort of gaming/productivity mouse, or a combination (with or without the help of AutoHotkey), there is a lot you can do to streamline and improve your day-to-day practice.

(See this post for a thorough breakdown of microphones, mice, peripherals, and other workstation equipment).
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