Physician Survey Signup Bonuses

The current welcome bonus landscape:

  • Curizon is entering new physician registrants in a drawing to win $100 (5 winners this month). The odds aren’t bad, one of our readers won in February!
  • All Global Circle is offering $50.
  • InCrowd is offering $10.
  • M3 is offering $10 for signing up through the end of June (with additional $20 bonuses for attempting six surveys or referring a friend from a target specialty).

My complete list and more thorough descriptions can be found here.

In addition to being a way to earn extra money (and start a side business that enables you to take some business deductions), signing up through these links also helps support my writing. Thank you!

RadPartners’ Partners are not Partners

I posted two tweets the other day that deserve some further discussion:

I’ve since by told by another source at RP that this is actually the third quarter in a row that profit-sharing has been delayed.

These “unique” payments are the ubiquitous practice of a group putting money in your 401k. “Profit sharing” is just the actual term used by the IRS. Practically, these contributions are just a portion of your compensation that is tax-deferred. For reference, my group contributes to my 401k on a monthly basis.

Now, I am obviously not privy to RP’s internal workings, but I suspect these delays are twofold.

One, RP is suffering from cashflow/liquidity issues. That’s what they essentially say in the email snippet I’ve shared above.

Two, businesses have an incentive to delay payments/hold onto cash thanks to the time value of money: having money now instead of later is itself worth money–because you can invest it. By holding onto their radiologists’ money for longer, they can keep these funds earning interest, which helps their bottom line. This is a big reason why insurance companies delay care through denials and prior auths even for the things they know they will eventually cover. It’s also why Starbucks is basically a bank that sells coffee: they have over $1 billion in giftcards. Starbucks gets to invest all of that prepaid money before they incur the cost of actually giving you that delicious brown sugar oat milk shaken espresso.

The easiest way to make money is to have your money work for you.

RP needs (or believes they need) to do this now. Also note, these delays also started around the time RP laid off some of its nonclinical workforce.

This feels like part of a story.

When a “Partner” isn’t a Partner

The other word we need to address is partner.

It should almost go without saying that I can’t vouch for how every contract looks, but here’s the language for one of RadPartner’s “partnership” employment agreements:

Partnership Designation:
During the Term, the relationship between Physician and Practice shall be that of employee and employer and shall not modify or affect the physician/patient privilege or relationship. Unless otherwise directed in writing by the Chief Executive Officer of Practice, the Physician may refer to himself/herself as a “Partner”, allow others to refer to him/her as a “Partner” and refer to such other employees of Practice who have executed this Form of Employment Agreement with Practice as his/her “Partner”, provided, however, that the designation of “Partner” shall be in name only and the Physician shall not be an owner/partner of Practice under the law. Further, Physician shall not have any power or authority to bind Practice in any way, to pledge its credit or to render it financially liable for any purpose unless formally appointed an officer of Practice with such authority pursuant to Practice’s governing procedures and law or authorized in writing by the Chief Executive Officer of Practice.

You are a “partner” in name only.

This is the inescapable reality of choosing a “partnership” track job with an RP group. You are putting in the work in order to take on the responsibility of running the practice without actually owning the practice. It’s just verbal sleight of hand.

Evaluating “Partnership” Opportunities

Sometimes people reach out to me with employment offers and other quandaries for my opinion. (NB: Please note that I am a Person on the Internet and not an expert on most things including contract review).

A reader recently reached out asking for my thoughts on their partnership-track teleradiology-only employment offer with an RP-owned group. The offer included a decent workup salary with high productivity demands that I doubted most people fresh in practice would be comfortable hitting. As in, the W2 sounded very competitive on paper but was actually still pretty extractive taking into account the desired production. That’s not really news. All practices function this way at least to some extent. Partners make money on their employees.

The job also promised “full partnership” in two years with “equal profit sharing.” And this is the crux:

It’s true that whether you work at an independent practice or a private equity-owned group, the “profits” can always be zero. But the profits at an independent group are the profits (revenues minus costs). The profits at an RP group are something else. As United Healthcare argued in its recent lawsuit:

In exchange for these services, Radiology Partners siphons off large amounts of revenue from the medical groups. Indeed, on information and belief, the affiliated medical groups no longer retain any profits resulting from the radiology services that they provide, and all profits are instead kept by Radiology Partners.

An equal share of zero is still zero.

The stock offered to new RP employees is also almost certainly worthless. Don’t view the chance to catch a falling knife as a growth opportunity.

*  *  *

I promise I don’t begrudge anybody their career choices.

And you absolutely don’t need to consider what Random Guy with a Website says.

But if I were considering a job offer at an RP group, I would consider only the workup/employee salary and not make a decision based on the possibility of future increased income as a “partner.” I keep annoyingly using air quotes here for the same reason RP does: There are no partners. There is no partnership.

In each group, there are people who make less money and people who make more money, but they are all employees, and none of them are really actually entitled to much of anything. I won’t pretend to tell you what fraction of groups are happy with their sales and what fraction of groups are making good money and what, if anything, reliably differentiates the successful groups from the struggling ones. That kind of granularity is something that only RP knows, if anyone knows at all. But this much is undeniable: the partners are just employees who are usually paid more. 

*  *  *

If trainees flock instead to independent groups, then radiology private practice will stabilize and the independent model will survive. If they instead take one of the infinite positions offered by RP and their ilk, then they are casting votes for the corporate practice of medicine. I don’t have a crystal ball, but I remain concerned that the downstream consequences of that often understandable individual choice made en masse will be the tacit endorsement of the funding model and the acceleration of falling reimbursement and radiologist replacement.

If you want to work for RP, another PE company like Envision or Lucid, or ride the current wave of teleradiology positions that pay relatively well, then you can do that. You don’t owe the field of radiology more than you owe yourself or your family. But it would probably be wise to assume that it is a temporary play and that some component of your job, either the money itself or the quantity of work asked of you, will change in the coming years. Radiology is in the middle of a nationwide shortage that will morph into a big unpredictable shift. Lots of radiologists change jobs, so you certainly won’t be alone.

Some of these are undeniably good employee positions right now. But don’t think for a second that a private equity partnership means you own the business. Because you don’t.

The ABR Discusses the New Oral Boards

Here is the video for the American Board of Radiology’s town hall discussion about the new oral boards, which are coming to a computer near you in 2028:

Some highlights:

  1. The ABR would like you to know that discussions about revamping the Certifying Exam started internally and “did not arise from an assumption that there was something wrong with the Certifying Exam.” (There is.) They did acknowledge that “nuance is lacking in the current exam.”
  2. Any interesting formats such as simulation-based assessments weren’t possible due to “practical constraints.”
  3. With regard to data about the effectiveness of either the old oral boards format or the current exams, Executive Director Dr. Wagner said: “We have no data that it DOES work.” He went on to say that proving the ABR exams have an impact “would be a difficult experiment to run.”
  4. The initial timing will be during the second half of fellowships (first offered in 2028), but while the format is set, the timing would “not be hard to change” in the future if needed.
  5. They will send out a “mock session” in the next few weeks apparently. I hope they also intend on releasing sample cases with sample scoring rubrics as well.
  6. When asked about exam preparation/support from fellowships, Dr. Wagner said: “The ABR doesn’t really have a position on that, as to how a candidate should prepare.”
  7. In the following discussion, the implication was that likely most preparation would take place during the fourth year of residency. It was not specified as to why it should be deep into fellowship (the phrase “the least bad choice” was used.) When asked why not just offer the Core and Certifying exams simultaneously or back to back, the ABR’s answer was that they were not interested in changing the need to pass the Core exam first in order to take the Certifying Exam, and the Core Exam takes time to grade. (But, yes, we could, again, in principle, just have written and oral exams like we used to.)
  8. There will be no “hardcore” physics or non-interpretive skills.
  9. The plan is for 7 25-min sessions with 10 min breaks between each. There will be an extra session (“recovery block”) at the end in order to deal with internet failures during the exam day.
  10. The ABR currently spends more than $200 per item to develop its multiple-choice question collection. This exam won’t cost more, because no one will travel, the number of items is far smaller, and the judges are volunteering. In reality, this exam will be much cheaper. But also: no, they won’t be dropping fees.

Want more? Here is my initial discussion of the coming change.

We’re hiring!

All of this recent talk of the nationwide radiology shortage and I’ve been remiss in not also mentioning: like every other practice in the country, we’re hiring!

Our 100%-independent physician-owned radiology practice of which I am a partner/shareholder is hiring in almost every subspecialty including breast, body, neuro, neuro IR, MSK, ER, and general. Everything except VIR at the moment. While all of our partners are in the Dallas/Fort Worth metroplex, we have some openings for remote employees and independent contractors.

We’re privademic: we have part of the practice that works with residents at a university hospital and we have part of the practice that does not. I enjoy a nice mix.

I’ve written before about why I believe some job healthcare models are problematic, and why not all attending jobs are created equal. I’ve also written before about how to approach getting your first job out of training. My perspective and biases about radiology practice are on full display.

Our group was/is my first job out of training. It was the job I wanted–so much so that the day I got the interview invitation email (after already having job offers waiting for a response), I did an actual Street Fighter dragon punch of victory and told the others they were going to have to wait past their response deadlines. I was drawn by two things:

  1. A well-established successful privademic model combining teaching-focused academics with the no-BS of private practice (with positions leaning more in different directions based on interest including pure no-teaching PP), which gave me the chance to teach and work with trainees in a more flexible environment than a traditional big academic bureaucracy. I’m currently the associate program director for our residency, and our residents are awesome.
  2. A sustainable job model combining high-quality (as opposed to only high-volume) radiology practice with reasonable daily expectations and the goal of a standard 4-day workweek for those who want it (tomorrow is my day off!). I wanted the time and mental space to also be a partner at home and have the flexibility to do the other things that are important to me (like this). My colleagues are good at what we do, and I still learn from them every day.

So if you’re in the market, come work with me and check out our great team in Dallas. If you’re interested, send me your CV at and I’ll make sure it gets where it needs to go.

ChatGPT Passes a Written Radiology Exam

ChatGPT’s newest version, GPT4, was able to pass a no-image multiple-choice radiology exam.

GPT4 is neat, but this says a whole lot more about how useless and off-base a radiology exam without pictures is than about how ready for prime time the current AI tools are. But they’re coming, and I for one am interested to see more natural language processing combined with what’s already out there to actually make healthcare more efficient (automated discharge summary drafts! a real summarized history on imaging orders!)

The authors also do note that when GPT4 is wrong, it’s often wrong in spectacular ways (and will boldly make up lies with the same confidence as it dishes out true answers). As in, not quite ready for anything when real performance counts.

Envision: A Very, Very Big Private Equity Bankruptcy

It took a few years before it finally got there, but massive private equity-owned physician staffing company Envision finally filed for Chapter 11 bankruptcy this week.

The harbinger of the coming wave of PE defaults, bankruptcies, distressed exchanges, and other failures has fully arrived. Make no mistake, this is just the beginning.

There are people who see this news and rejoice. It’s not hard to see why. There might be more than a bit of schadenfreude seeing a big private equity company go belly up. These entities are so often in the business of pure value extraction. They aggressively use leverage to buy a bunch of stuff using a bunch of borrowed money and try to increase profits through negotiating clout, suppressed salaries, and unsavory financial machinations. They often take successful companies and saddle them with so much debt that they fail, strip them for parts, and let everything fall apart after they’ve made sure they made their buck. Many of the big retail failures of the past decades have all been the same story.

Envision was in the process of the usual playbook of financial machinations to separate the profitable wheat from the debt-riddled chaff when the WSJ reported on the possible impending bankruptcy and forced their hand.

Because such a large portion of their purchases are funded through debt, it’s relatively rare that the PE-owner actually loses a ton of their own money in the process. Envision’s owner KKR wasn’t quite so lucky: while the levered buyout was almost $10 billion in 2018, they are still likely to lose their entire ~$3.5 billion stake.

A Fall Long Coming

Envision’s reimbursement games didn’t pan out, not just their ploy of going out of network to charge exorbitant rates to unsuspecting patients–a practice curtailed by the No Surprises Act–but also from the bad acting of big payers like UnitedHealthcare (there are very few good guys in healthcare). Adding insult to injury, they weren’t able to squeeze physicians and other staff in the hot job market. Labor costs have been going up.

While Envision as a normal business is functioning, valuable, and generates cash, its growth was nowhere near the level required to service its more than $7 billion of debt. If the credit markets were loose like in the pre-Covid era, they probably would have been able to refinance without issue. Now, the cost of capital is simply too expensive.

This possibility was in the news back during the early Covid days, but Envision was temporarily saved by an influx of cash from the CARES Act. They recently defaulted on their debt and subsequently filed for Chapter 11 bankruptcy on May 15.

From the announcement email from Envision CEO Jim Rechtin:

Upon emergence from the restructuring, both Envision and AMSURG will be under new and separate ownership, comprised of current lenders. KKR will no longer have a stake in either company.

The email goes on to state the following items unironically:

  • Envision and AMSURG are not going out of business. The filing ensures an orderly process for restructuring our debt and finances. This is not a liquidation.
  • Our clinicians and clinical support teammates can expect to receive their normal wages and benefits. Independent contractors and locums can expect their usual payments.
  • The filing does not change the regular work schedules of our clinicians or clinical support teams – operations will be business as usual.
  • Our top priority is continuing to deliver high-quality care and supporting our hospital partners and surgery centers without interruption to services.
  • There should be no change to the quality of service our patients and their families have come to expect from us.

As part of the process, Envision is now owned by its creditors (the lenders who had given secured loans and/or purchased corporate bonds,) and KKR has lost its stake and will no longer own/run the company. And it’s worth pointing out that nothing unsavory has really happened in the sense of business practice. This is how the industry is designed to work. People invest money and take on risk in order to make money. A company taking on debt it knows it can’t really afford and other unnecessary/excessive risks that might screw over its creditors is part of the game. When companies fail, the creditors get the scraps before the equity owners/shareholders.

Billions of dollars have been lost, absolutely, but at the end of the day, it’s mostly big institutional investors like large pension funds that are the ones who have lost in the short term. KKR made a bet and lost. They’ll be fine.

Of interest to most physicians is that the day-to-day function of Envision probably won’t change much, and this big company that got big by borrowing an unsustainable amount of money to fund its growth still exists. It may even emerge from this process potentially stronger than recent years now that it won’t have billions of dollars on the balance sheet and the need to make periodic debt payments. They will probably not be able to raise more capital in the current environment, which will prevent the kind of debt-fueled highly-leveraged growth that allowed a company like Envision to buy large practices in the first place. And their management record still does not inspire confidence. But at the end of the day, Envision as an entity is still big, still employs thousands of doctors, and still has a dominant market position in several locales. If there is any physician staffing company that could be considered too big to fail, Envision is one.

You might ask, why would Envision’s creditors take the deal? Is losing billions of dollars fun? Well, no. This is the nature of distressed exchanges: better to lose a few billion and end up with a big profitable company at the end than lose all of your billions.

What Next?

From the official FAQ:

How will patients be impacted?   
Patients will continue to receive the same high-quality, high-value care our clinicians and physician partners have always provided. Patients and their families should notice no difference in our operations or level of care.

This is why those hoping that the collapse of private equity-funded healthcare ventures will lead to a return to better times are unfortunately in for a grim reality check. The tactics and market consolidation don’t have to go away just because they can’t pay their debts. We’re not likely to undo any damage already done. For better or worse, these companies will mostly soldier on. The playbook lives to see another day.

Unless physicians quit in droves on principle or in fear, the status quo continues. If people take the wake-up call about the flaws in the funding model, that’s a different story.



Prompting Equity

People have really enjoyed asking the current generation of large language models (LLMs) like ChatGPT about AI: a sort of overly on-the-nose meta-discussion. Reid Hoffman, co-founder of LinkedIn and techno-optimist/evangelist, co-wrote a free book about AI with GPT-4 called Impromptu: Amplifying our Humanity Through AI.

In a late chapter, Hoffman makes an argument that modern humans are homo techne (“the technological human”), essentially that “technological innovation is, and always has been, humanity’s defining feature.” He talks about the many inventions of the past and how amazing it has been since the early 1920s. For example:

Whoever you were in say, 2005, you are—if you regularly use a smartphone now—a dramatically enhanced version of that person. (p. 192)

GPT-4’s response is a bit more nuanced:

I don’t necessarily disagree with any of the points you made, but I think it’s important to remember that not everyone experiences these benefits equally. For example, while it’s true that the average human life has doubled in the past hundred years, there are still parts of the world where life expectancy is much lower, due to poverty, lack of access to healthcare, or other factors. And while smartphones and other technology have certainly made our lives easier in many ways, they can also exacerbate existing inequalities—for example, by making it easier for those who can afford them to access information and opportunities, while those who can’t are left further behind. So while I don’t disagree that we’re living in an incredible time, I think it’s important to keep in mind that these benefits aren’t universally shared.


That’s a very important point. Do you think modern emerging technology can help us democratize these benefits, or otherwise address long-standing equity issues?


I think it’s definitely possible. For example, telemedicine could help address the lack of access to healthcare in under-resourced areas, and technology that allows for remote work or online learning could create new opportunities for people in rural or impoverished areas. But I also think that it’s important to remember that technology is only a tool—it’s up to us as a society to make sure that it’s used in a way that promotes equity and benefits everyone, rather than just a select few.

There’s a certain grain of techno-optimism that’s almost as tedious as the doomsaying: the belief that good arises organically as a feature of the technology itself as opposed to from the human systems that deploy it.

For a lot of people, the early democratic internet seemed to bear this out. This is what I thought as a middle schooler playing online hand-coding websites in HTML to post on Geocities. The whole thing is magic! And then we got Wikipedia–amazing! But I think in the era of social media and conglomerate capitalism, we should all know better by now. Hoping everything gets so profoundly broken that the governments of the world will be forced to provide a universal basic income (UBI) but that otherwise no harm is done is probably naive.

GPT4 is derived from the content of the internet. While the model is tuned to provide more useful and less racist/sexist/terrible responses, the fact that its statistical process is able to generate responses like this suggests to me that the people who have written about this publically have probably thought about it correctly. I don’t know if we’ll listen.

Unofficially Official ABR Core Exam Practice Questions

Years ago, when I was a resident and the ABR Core Exam was still novel, the ABR offered a lengthy “ABR CORE Examination Study Guide” PDF, which–in addition to over a hundred pages of endless bullet points listing every conceivable topic in radiology–included 57 official practice questions at the end (with an answer key).

They took that down years ago. But, thanks to the miracle that is The Internet Archive, you can still enjoy a copy of that PDF here. Well worth doing in the final weeks leading up to the June exam. Enjoy!

(Other nonofficial question resources are discussed here.)

((Lest there be any confusion, I have no working relationship with the ABR. In fact, I’m probably a persona non grata. These are just questions that they once posted on a public-facing website.))