The ACR’s RLI Leadership Essentials 201: Preparing for Practice is “a virtual, 4-month [Sept. 1–Dec. 31, 2026] professional development program designed to help residents and fellows build leadership and professional skills often not covered in traditional radiology training but highly valued in practice.” Totally free for ACR members (which is free for trainees).
From an article about RANT’s fight with BCBS in Radiology Business:
Under the No Surprises Act, enacted by Congress in 2020, physicians and payers can settle disputes over out-of-network healthcare services. This is meant to protect patients from unexpected bills, which proponents say the NSA is achieving. Radiologists and other docs are reportedly winning in the “independent dispute resolution,” or IDR, process at a high clip. The law allows these outside arbitrators to issue binding decisions for imaging and other services, but health insurers are now refusing to pay up afterward.
Radiology Associates estimates it has prevailed in about 95% of finalized IDR disputes with Blue Cross Blue Shield of Texas, the state’s largest insurer. However, more than $3.5 million in awarded balances remain unpaid. RANT estimated that $1.64 million of this total has been outstanding for over 120 days. As of Tuesday, BCBS Texas has paid approximately 2% of awarded balances.
RANT also expressed concern about restrictions around how radiology practices can batch together claims to be submitted to the IDR process. Current rules force the practice to divide similar claims into thousands of smaller arbitration filings, each carrying separate filing and IDR fees. Under current federal interpretation of the law advocated for by BCBS of Texas, Radiology Associates says it will file over 68,000 payment batches, with total administrative cost of nearly $53 million. Under an ideal process, RANT estimated it would have submitted 1,369 batches for a total administrative tally of $1.05 million.
Say what you want about the NSA, but it’s the law of the land. Losing in binding arbitration and then not paying the awards is bullshit. If an insurance company doesn’t like the awards when they lose, they can negotiate in good faith and get the physicians back in-network.
Also, the interpretation to limit the batching of essentially identical claims to tiny numbers will only make the process more cumbersome, less efficient, and more expensive. It also makes it challenging for real practices with limited cashflows to afford, which is, of course, the whole point. It’s a terrible implementation of the law.
In “Why Is It So Hard to Be Ordinary?” Joshua Rothman cuts deeply for The New Yorker:
What’s true for Little League holds for the rest of life. In some contexts, at some times, we strive for excellence, pushing ourselves. Elsewhere, we shrug, accepting our own ordinariness or mediocrity. The excellent and the ordinary coexist, but have an uneasy relationship. With phrases like “you win some, you lose some,” we acknowledge how, on an ordinary day, in an ordinary life, events cluster around a medium level of quality; in theory, we could be happy in the range between not-so-bad and pretty-good. Yet, for many people, it becomes difficult to find satisfaction in what’s regular. The excellent starts to shame the ordinary, leaving it worse off. We want to play winning seasons, not average ones. Having dunked once, we’d like to keep doing it. We’d prefer “great” weekends and vacations. On the largest scales, we oscillate between wanting to lead extraordinary lives and embracing the “merely” ordinary.
To paraphrase: if the questions are, is this it? Is this all there is? The answer is yes.
From Verdad’s “Priced for Perfection“:
The future is too uncertain and unpredictable to make high-certainty bets. Yet today’s market—and today’s largest tech companies—are taking one of the largest bets in the history of economics on the future of a new technology. One does not need to be a bear on the technology itself—we are power users and love AI—to identify that this moment in market history is likely to be characterized by over-investment, over-spending, excessive valuations, and inevitable disappointment as an uncertain future surprises a consensus narrative that is too specific and too confident relative to the pace of change.
Predictions are hard, narratives a bit easier. It will be interesting to look back at all the bold predictions and hand-wringing in 2, 5, 10 years and see who is eating claim chowder.
From Leonard Mlodinow’s Feynman’s Rainbow: A Search for Beauty in Physics and in Life, a memoir about his early career as a physicist and working in the same department as titans Richard Feynman and Murray Gell-Mann:
People sometimes scoffed at academia because of the relatively low pay. But I had seen too many “adults” work too many hours at jobs they did not like in order to amass things they only thought they needed, and then, decades later, regret their “wasted” years. And I had seen my father work long, arduous hours just to make ends meet. I had vowed to have a better life than that. The most valuable asset I figured I could earn was the ability to spend my time doing something I liked.
When you select your medical school, your residency, your next job, or how you’re working in your current role—what are you optimizing for?
There is a flip side to the comforting knowledge that everyone is just stumbling through the fog, and that is that it is a pretty good bet that many of them are not stumbling in the right direction. Who is going down the blind alley and who is on the road to success? Whose work will be remembered and whose forgotten? What is worth doing, and how do you know? I didn’t have the answers, but I thought back on the pep talk the division chair had given me. Explore, he said. Check out what other people are doing. I decided to open myself to others.
In considering the explore-exploit tradeoff, we are often jealous of those who seem to have it all figured it out. It is a mistake, however, to assume they’ve always figured it out correctly or that their solutions can be taken on wholesale.
The creative mind has a vast attic. That homework problem you did in college, that intriguing but seemingly pointless paper you spent a week deciphering as a postdoc, that offhand remark of a colleague, all are stored in hope chests somewhere up in a creative person’s brain, often to be picked through and applied by the subconscious at the most unexpected moments. It is a part of the creative process that transcends physics. For instance, Tchaikovsky wrote, “The germ of a future composition comes suddenly and unexpectedly. If the soil is ready…” And Mary Shelley: “Invention does not consist in creating out of void, but out of chaos.” And Stephen Spender: “There is nothing we imagine which we do not alread know. And our ability to imagine is our ability to remember what we have already once experienced and to apply it to some different situation.”
I love this description of creativity, derived from a full, vibrant life, broadly sourced and even full of randomness.
Hanging around a grown kid like Feynman made you question things. Like all the things we do in life because we have to do them—or at least we think we do. Sitting through boring meetings with colleagues or customers or clients when we’d rather be outside staring at a rainbow, or managing our careers along some path for which we have no passion merely because it is supposed to be the road to success. Like my young boys today, Feynman was startlingly honest with people, including himself, and you couldn’t make him do anything he didn’t want to do, at least not without grumbling. In contrast, there I was, still free to choose my own path, and I was compromising almost before I began. What, for me, was worth doing? What would give meaning to my life?
[…]
WHAT IS IMPORTANT IN LIFE? It is a question we should all give thought to. The answer is not taught in school, and it is not as easy as it may seem, for a superficial answer is not acceptable. To discover the real truth you have to know yourself. Then you have to be honest with yourself. Then you have to respect and accept yourself. For me, these were all tough tasks.
I had gone through college and into academia in a hurry, wanting to rush ahead with my work, to prove to the world that I had been alive, and that it had mattered. That was an external focus to life. That was Murray’s way. To accomplish and impress. To be an important person, and a leader. It was the classical path. The traditional one. It seemed to be an obvious and worthy goal. I had accepted it without second thought. But for me, it was like chasing a rainbow. Even worse, it was like chasing other people’s rainbows. Rainbows whose beauty I didn’t really see.
Feynman’s example caused me to rethink mine. He didn’t seek the leadership role. He didn’t gravitate to the sexy “unified” theories. For him satisfaction in discovery was there even if what you discover was already known by others. It was there even if all you are doing is re-deriving someone else’s result your own way. And it was there even if your creativity is in playing with your child. It was self-satisfaction. Feynman’s focus was internal, and his internal focus gave him freedom.
Different approaches to life—external validation vs internal motivation—as exemplified by two of the greatest physicists of the twentieth century.
There’s an exchange in the book I loved:
“Do you know who first explained the true origin of the rainbow?” I asked.
“It was Descartes,” he said. After a moment he looked me in the eye.
“And what do you think was the salient feature of the rainbow that inspired Descartes’ mathematical analysis?” he asked.
“Well, the rainbow is actually a section of a cone that appears as an arc of the colors of the spectrum when drops of water are illuminated by sunlight behind the observer.”
“And?”
“I suppose his inspiration was the realization that the problem could be analyzed by considering a single drop, and the geometry of the situation.”
“You’re overlooking a key feature of the phenomenon,” he said.
“Okay, I give up. What would you say inspired his theory?”
“I would say his inspiration was that he thought rainbows were beautiful.”
I looked at him sheepishly. He looked at me.
“How’s your work coming?” he asked.
I shrugged. “It’s not really coming.” I wished I was like Constantine. It all came so easily to him.
“Let me ask you something. Think back to when you were a kid. For you, that isn’t going too far back.
When you were a kid, did you love science? Was it your passion?”
I nodded. “As long as I can remember”
“Me, too,” he said. “Remember, it’s supposed to be fun.” And he walked on.
Remember, it’s supposed to be fun.
Fun times at Meta, including jobs cuts and mandatory spyware to help train your replacement:
…the company introduced mandatory software onto corporate laptops that tracks what US employees are typing and clicking to gather data to train AI models that execute tasks such as web browsing or organizing folders on a computer as a human would. Opting out is not possible, according to three employees. “Nobody is happy about it,” says a current employee. “And we have no choice.”
The software, known as Model Capability Initiative, or MCI, suddenly turned people across the company into privacy zealots, a legal staffer says. When employees protested the rollout in internal messages, including by referencing Meta’s history of user data breaches, chief technology officer Andrew Bosworth “belittled and berated” the dissenters, one veteran employee says and another confirms. “These billionaires can’t even feign empathy,” the first person says. “The social contract is completely shattered at this point.”
From Michael Porter’s Redefining Health Care: Creating Value-based Competition on Results, published twenty years ago in 2006:
Competition in the current system is too local, because it is centered on relatively small, self-contained local institutions catering to local needs. Services are both delivered locally and managed locally. The local bias in health care is a throwback to an earlier era when medical care was less complicated, and travel more difficult. It has been institutionalized by prevailing ownership and governance structures for provider institutions, regulatory and reimbursement practices, and a lack of local provider accountability for performance.”
I’m not sure this claim gets to the root cause of the problem.
Healthcare is inherently a local business like most service businesses, but much of this is unavoidable in the sense that people are local. Unless we want to move further and further into the telehealth era, that will remain the case. And some services, including most emergency and a lot of procedural care, local remains unavoidable (until/unless we have robotic telepresence).
The intervening 20 years have shown us a remarkable degree of increasing regional hegemony in healthcare, and it hasn’t been great. Without that parochial, inefficient local competition, the real result has been no real competition at all. Just big battles between payors and systems.
I also don’t think this is the case:
Moving to value-based competition on results will require significant changes by all system participants, as we have noted. However, the system can, and will, change from within. Each system participant can significantly improve value, and reap the benefits, even if nothing else in the system changes.
Value sounds straightforward, but it’s so hard to define and, in many cases, extremely gameable. There are no magic metrics to durably measure quality.
The failure of competition is evident in the large and inexplicable differences in cost and quality for the same type of care across providers and across geographic areas. Competition does not reward the best providers, nor do weaker providers go out of business. Technological innovation diffuses slowly and does not drive value improvement the way it should; instead, it is seen by some as part of the problem. Taken together, these outcomes are inconceivable in a well-functioning market. They are intolerable in health care, with life and quality of life at stake. They are unsustainable in a sector that consumes a large and growing portion of the national budget.
What’s not captured here: pricing is supply/demand filtered through size/scale/negotiation. Healthcare is not a free market, and those participating in government or commercial insurance do not set their prices and in many cases do not really compete on prices.
Price transparency isn’t enough. Not only is healthcare local, which limits your options (e.g. you probably aren’t going to travel to a faraway hospital for acute pneumonia), but the consumer has no benefit to minimizing costs if they have a plan with an out-of-pocket maximum that they are going to hit, for example.
Rather than measuring results and rewarding excellent providers with more patients, the focus has been on lifting all boats by attempting to raise all providers of a service to an acceptable level. The principal tools have been practice guidelines and standards of care that every provider is expected to meet. Evidence-based medicine is another term for practicing based on accepted standards of care.
Defining excellent performance is actually very hard. Defining outlier performance is relatively easy.
Competition takes place on broad service lines, not individual services. Providers offer every possible service, and gear up to handle any patient who walks in the door. Health plans contract with providers across the board. Yet breadth of services per se has little impact on patient value—it is the ability to deliver value in each medical condition that matters. Health plans and providers have merged and consolidated, but the pursuit of breadth and the duplication of services have only increased. As system participants compete on breadth, competition at the medical condition level has been suppressed or eliminated by health plan networks, captive referrals within provider groups, and the almost total absence of relevant information.
This is true. Furthermore, even in places where some high-quality providers exist, the volume/profit game has led to expansion with lower quality. An outstanding clinician you can’t see doesn’t help you when her panel is full, and even the internal referrals from doctor to doctor within systems get filtered to a growing army of midlevel practitioners.
From Arthur C. Brooks’ The Meaning of Your Life:
My psychologist friend said something else that proved revolutionary for my thinking—and, in fact, my whole life: to give a great deal to one person is even more empowering than to give a little to a lot of people. In other words, making a big, tangible difference to one person’s life has a much greater meaning-creating self-transcendent effect than writing checks to a bunch of charities (as worthwhile as that is). This is an ancient idea; it is written in the Mishnah Sanhedrin section of the Jewish Talmud, for example, that “he who saves a single soul saves a whole world.”
Randomly writing on the internet aside, finding ways to be involved with individuals (family, community, education, and mentorship) are real paths to fulfilling variety.
The lowest level of work motivation is “necessary evil.” Finding meaning in work that you hate is difficult. In fact, if you hate your job, it can inhibit a sense of your life’s meaning. Above this is work as a duty, such as that which you do to be a productive citizen and to support those you love. Fulfilling a duty is, of course, meaningful. My family is meaningful to me, and thus, so is supporting them. However, ideally you can do better than just that, by seeing your work as a means to practice excellence and virtue—that is, honing your craft. Even higher in meaning is service to others, beyond just economic support.
Even when the job isn’t perfect or is just a temporary step on a longer journey, approaching it with the Craftsman’s Mentality makes it better. Striving and excellence have positive echoes.
Psychologists have studied this mysterious sense of calling in depth and often say that it requires having a “subjective career,” as opposed to an “objective career.” The difference between the two is how success is defined. Objective careers focus on money, power, and prestige. Subjective careers are more focused on earned success and service to others. Earned success is the opposite of an old idea in psychology called “learned helplessness,” which is what occurs when people feel like no matter what they do, their rewards or punishments aren’t affected. For example, you are paid and promoted the same as everyone else, regardless of how you perform. Alternatively, you are not rewarded or are treated poorly even when you excel in your work. This leads to feelings of resignation, futility and, often, depression about life in general.
I appreciate the conception of a “subjective career” and “earned success” over “learned helplessness.” When we think of bad places to work and bad cultures, it is where democracy or fairness have been subverted in favor of sameness, where A players and C players are equivalent (or, even worse, when the willing are coopted to do do do because their yes-nature is exploited until burnout and the sloths and dishonest are tolerated).
Earned success means being recognized and rewarded for merit and personal responsibility. I work a lot with companies seeking to bring more meaning and happiness to the workplace, and one of the things I stress the most is this idea of earned success through honest, clear, merit-based systems. This is hard for weak leaders, who don’t like holding people accountable or acknowledging that aptitude and work effort differ between people and some are more excellent than others. To avoid conflict, these leaders prefer tenure- or loyalty-based systems, which strip work of meaning and drive away good people.
Holding people accountable is actually extremely hard, which is why it’s so often just not done except for either egregious cases or petty reasons. Dr. Death practiced medicine for years. Fairness does not equal sameness. The apathetic management style—low expectations and low support—may often be an understandable reaction to the real world, but it also further hollows out organizations and leads to a disengaged and unresilient workforce.
The point is that you can look for your calling without being a lifesaving paramedic or feeding the hungry. Simply being a great team member, a kind coworker, a considerate and caring manager, all count. Serving others doesn’t have to be heroic to achieve self-transcendence and the sense of meaning you crave. Even if your job is not extrinsically rewarding, you can start generating your own intrinsic rewards.
I still don’t like the idea of a calling. I think what Brooks refers to as a calling is really mostly a good attitude. But, a good attitude is also the greatest gift you can give yourself. It’s also one you can easily take away, and one that—for most of us—requires practice giving again and again.
From the conclusion of Anthropic’s article summarizing their own research into AI-assistance and skill formation:
Our results suggest that incorporating AI aggressively into the workplace, particularly with respect to software engineering, comes with trade-offs. The findings highlight that not all AI-reliance is the same: the way we interact with AI while trying to be efficient affects how much we learn. Given time constraints and organizational pressures, junior developers or other professionals may rely on AI to complete tasks as fast as possible at the cost of skill development—and notably the ability to debug issues when something goes wrong.
For novice workers in software engineering or any other industry, our study can be viewed as a small piece of evidence toward the value of intentional skill development with AI tools. Cognitive effort—and even getting painfully stuck—is likely important for fostering mastery.
De-skilling is, I think, a real and serious problem. Under-skilling and never-skilling are potentially an even bigger deal, and fighting it could be a generational imperative. We need people to do some serious practice on hard mode so their learning isn’t short-circuited.
From “Changes in Nonprofit Hospitals’ Finances, Operations, and Quality of Care After Using Management Consultants,” published in JAMA:
Nonprofit hospitals in the US (n = 2343) collectively spent more than $7.8 billion on management consulting services from 2009 to 2023. A stacked difference-in-differences design comparing 306 US nonprofit hospitals that used a management consulting firm for the first time with 513 matched hospitals that did not use a management consulting firm during the study period found little evidence of substantial, statistically significant, or systematic changes attributable to management consulting engagements.
No surprise there. As the saying goes, “capable of anything and culpable for nothing.”