Asides are a microblog of shared links and quick thoughts.
They're on the main page but also all collected here.
Think of it like a Twitter feed without the awfulness.

Fresh off the press in AJNR:

Lower [neuroradiology] shift volumes yielded significantly lower error rates. The lowest error rates were observed with shift volumes that were limited to 19–26 [CT/MRI] studies. Error rates at shift volumes between 67–90 studies were 226% higher, compared with the error rate at shift volumes of ≤ 19 studies.

I wonder, are there any places in the world routinely reading ~20 cases per shift?

// 01.29.24

C.S. Lewis (of Narnia fame) on peer learning:

It often happens that two schoolboys can solve difficulties in their work for one another better than the master can. The fellow-pupil can help more than the master because he knows less. The difficulty we want him to explain is one he has recently met. The expert met it so long ago he has forgotten.

I’ve always been a big proponent of peer teaching and peer mentoring in medicine. I also often wonder if I’m getting worse at teaching the basics as I get older.

// 01.15.24

From “How to Do Great Work” by Paul Graham:

Schools also give you a misleading impression of what work is like. In school they tell you what the problems are, and they’re almost always soluble using no more than you’ve been taught so far. In real life you have to figure out what the problems are, and you often don’t know if they’re soluble at all.

Schools sometimes also give students the misleading impression that learning is not fun for its own sake and that writing should be boring.

// 01.04.24

From “The Bitter Lesson” by Rich Sutton:

In speech recognition, there was an early competition, sponsored by DARPA, in the 1970s. Entrants included a host of special methods that took advantage of human knowledge—knowledge of words, of phonemes, of the human vocal tract, etc. On the other side were newer methods that were more statistical in nature and did much more computation, based on hidden Markov models (HMMs). Again, the statistical methods won out over the human-knowledge-based methods. This led to a major change in all of natural language processing, gradually over decades, where statistics and computation came to dominate the field. The recent rise of deep learning in speech recognition is the most recent step in this consistent direction. Deep learning methods rely even less on human knowledge, and use even more computation, together with learning on huge training sets, to produce dramatically better speech recognition systems. As in the games, researchers always tried to make systems that worked the way the researchers thought their own minds worked—they tried to put that knowledge in their systems—but it proved ultimately counterproductive, and a colossal waste of researcher’s time, when, through Moore’s law, massive computation became available and a means was found to put it to good use.

[…]

We want AI agents that can discover like we can, not which contain what we have discovered. Building in our discoveries only makes it harder to see how the discovering process can be done.

// 01.03.24

In addition to being New Year’s, this site turned 15 years old (!) today. It contains hundreds of posts, over a half million words, and oodles of my time.

Thanks for reading!

// 01.01.24

My crystal ball is as cloudy as ever.

Earlier this month I wrote about Radiology Partners loaning a group money to help shore up radiologist compensation. That happened, but I was also wrong in my estimation of the likelihood of repayment: it turns out RP may be getting some of that money back after all.

The ultimate outcome is still up in the air, but I’ve addended my previous post with an update.

// 12.29.23

From “Serious Medical Errors Rose After Private Equity Firms Bought Hospitals,” reported by the NYT:

The study, published in JAMA on Tuesday, found that, in the three years after a private equity fund bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.

“We were not surprised there was a signal,” said Dr. Sneha Kannan, a health care researcher and physician at the division of pulmonary and critical care at Massachusetts General Hospital, who was the paper’s lead author. “I will say we were surprised at how strong it was.”

// 12.26.23

People like to operate under the belief that services like anesthesia, radiology, and pathology are totally interchangeable commodities. We do the work but don’t generate it, and patients generally don’t get to pick.

But in the real world, labor isn’t as cog-like as you might think, and culture matters (yes, even in our dysfunctional healthcare system).

Here, enjoy this story of a failed private equity anesthesia takeover.

// 12.12.23

The UnitedHealthcare vs Radiology Partners lawsuit went to arbitration instead of a jury trial last month. Last week, the arbitration panel ruled in favor of RP and its practice Singleton Associates, awarding them $153.5 million.

United, for its part, says it’s not done, and that there are still unaddressed counterclaims. From that Radiology Business article: “We do not agree that Singleton will recover an award from UnitedHealthcare,” the Minnetonka, Minnesota, company said.

// 10.24.23

Two great quick radiology podcasts, well worth your time for a better understanding of radiology in 2023:

First, the state of the radiology residency match and how things look for medical students as well as the radiology workforce, courtesy of Dr. Francis Deng (@francisdeng). I agree with everything he said, and he said it better than I would have. Listen here.

Second, episode 2 of the Texas Radiological Society’s “How Radiologists Get Paid” Podcast: a great discussion of the state of payment policy between Dr. Kurt Schoppe, policy wonk and my colleague across town, and Dr. Lauren Nicola, current Chair of the Reimbursement Committee at the ACR. If you want a better understanding of CMS reimbursement and what “quality” has meant recently in radiology, check it out.

// 09.28.23

From the short essay, “Energy Makes Time,” by Mandy Brown:

But there’s something else I want to suggest here, and it’s to stop thinking about time entirely. Or, at least, to stop thinking about time as something consistent. We all know that time can be stretchy or compressed—we’ve experienced hours that plodded along interminably and those that whisked by in a few breaths. We’ve had days in which we got so much done we surprised ourselves and days where we got into a staring contest with the to-do list and the to-do list didn’t blink. And we’ve also had days that left us puddled on the floor and days that left us pumped up, practically leaping out of our chairs. What differentiates these experiences isn’t the number of hours in the day but the energy we get from the work. Energy makes time.

The what is sometimes even more important than the how much.

// 09.04.23

From the free ebook A Manifesto for Applying Behavioral Science from the UK’s Behavioural Insights Team:

The other concern is that [behavorial science] theories can make specific predictions, but they are disconnected from each other – and from a deeper, general framework that can provide broader explanations (like evolutionary theory, for example). The main way this issue affects behavioral science is through heuristics and biases. Examples of individual biases are accessible, popular, and how many people first encounter behavioral science. These ideas are incredibly useful, but have often been presented as lists of standalone curiosities, in a way that is incoherent, reductive, and deadening. They can create overconfident thinking that targeting a specific bias (in isolation) will achieve a certain outcome.

Cognitive biases and mental models make for great blog posts but are really hard to put into practice as an individual or effectively guide policy as an organization.

For further reading, try Nudge (the new/final edition was just released in 2021).

// 08.28.23

In a similar vein to our recent discussion of radiology practice and game theory, this is from Andrew K. Moriarity’s new article in JACR, “Pirate Practice”:

Employed sailors could count on the guarantee of agreed-upon pay in return for work performed. However, each pirate must be primarily motivated to ensure group success by their own self-interest because each endeavor lasted only as long cooperation maximized profits over expenses.

[…]

In considering the cooperation needed among individuals for a successful voyage to keep moving forward, perhaps Jack Sparrow was right to conclude that “not all treasure is silver and gold, mate.”

// 08.24.23

Humans–with some incredible diligence and lots of practice–can do such fascinating things.

Pretty unreal.

// 08.23.23

Hold in the back of your mind the notion that someday you’re gonna write a book. You don’t have to write it this year. Meanwhile, writing begets writing. Just get into some kind of situation where you are writing, and if it’s some various thing you’re publishing online, it’s still grist to the mill.

Legendary nonfiction writer John McPhee in an interview with GQ at the tender age of 92. For further reading, see Draft No. 4.

// 08.22.23

From Tanner Greer’s The Scholar’s Stage:

The professionalization of intellectual pursuit is another problem. Melville would never have written Moby Dick if he had spent years enrolled in an MFA program instead of spending years at sea. Men and women who in past ages would have observed humanity up close (or at least who would have been forced through a broad but rigorous education in classics) instead cloister themselves in ivory towers. Their intellectual energy is channeled into ever more specialized academic fields and cautiously climbing a bureaucratic and over-managed academic ladder. Could that social scene ever produce a great work?

// 08.21.23

Great reporting by Cezary Podkul in ProPublica (and amazing perseverance by Dr. Shteynshlyuger):

A powerful lobbyist convinced a federal agency that doctors can be forced to pay fees on money that health insurers owe them. Big companies rake in profits while doctors are saddled with yet another cost in a burdensome health care system.

// 08.16.23

I’ll be giving the keynote at the FSU College of Medicine’s Business & Medicine Symposium in Tallahassee this Saturday. If you’re a student there, make sure to come say hi during the morning coffee or lunch after!

// 08.15.23

On my brief perusal, the eBook for Undergraduate Education in Radiology (developed by the European Society of Radiology) seems like a great and entirely free first radiology book for medical students and first-year residents. In particular, the sections I looked at included a great first pass of high-yield anatomy. Strongly recommended.

// 08.13.23

$39 billion of student loans were forgiven tax-free this month.

If you have any FFEL, Perkins, or Health Education Assistance Loan (HEAL) Program loans, please check out the IDR Waiver FAQ. You have until the end of 2023 to do a Direct Consolidation to make those loans eligible for loan forgiveness programs and count previous payments without resetting the clock.

// 07.20.23

From MONETIZING MEDICINE: PRIVATE EQUITY AND COMPETITION IN PHYSICIAN PRACTICE MARKETS, a report by the American Antitrust Institute:

Price increases associated with PE acquisitions are exceptionally high where a PE firm controls a competitively significant share of the local market. When we focus our analysis on markets where a single PE firm controls more than 30% of the market, we find further elevated prices associated with PE acquisitions in each of the 3 specialties with statistically significant results, for gastroenterology (18%), obstetrics and gynecology (16%), and dermatology (13%).

Discussed in the NYTimes here.

// 07.13.23

Jeff Goldsmith in “What Can We Learn from the Envision Bankruptcy?“:

Strategically, the Envision bankruptcy raises anew the question of whether there are economies of scale, and investment returns to scaling, in healthcare. Certainly the conventional wisdom argued that large firms like Envision had the ability to recruit and retain clinicians across vast geographies, and negotiating power with the large insurers that increasingly dominate key insurance sectors like Medicare Advantage and Managed Medicaid.

Envision’s demise strongly suggests that the power balance-both political and economic- has tipped decisively in the direction of payers like United. Rising interest rates, the increasing scarcity of clinicians as workaholic baby boom vintage docs and deepening financial challenges for the ultimate customers of many of these companies, namely hospitals, suggest that we may have reached an inflection point in the viability of many private equity physician care models, with their 4-7 year holding periods and a succession of owners. Current owners might find it increasingly difficult to exit their positions.

// 07.11.23

RadPartners is desperately trying to raise capital to pay off its debts via another round of equity funding (i.e. creating and selling new shares of preferred stock).

If successful, this would dilute the value of shares held by current shareholders (historically, ~40% of the company was owned by current or former RP radiologists). In reality, I have a tough time imagining any large investors putting enough good money into something predicted to go bankrupt within the next two years to shift the course of the Titanic.

// 06.29.23

The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”

From “The Moral Crisis of America’s Doctors.”

// 06.15.23

Graduating medical students: if you haven’t already begun, it’s around time to consolidate your federal student loans. The benefits are discussed in this chapter from my (free) book. While you’re at it, you should also probably read the whole thing.

// 06.11.23

Hi! I’ve been wanting to revamp my site for years, but some mandatory security updates have forced my hand, so now we’re in the middle of frantic unplanned unavoidable total website redesign (oops)!

Please excuse any quirks as I work on this in my copious free time.

// 06.07.23

The final trailer for the Super Mario Bros. movie dropped, and it looks like it might be the rare (only?) (did you like the Sonic movie?) video game movie that hits the important game notes for enjoyable fan service while also looking like a decent movie.

Our family is genuinely looking forward to seeing this one.

// 03.11.23

From “Nobody Has My Condition But Me” by Beverly Gage in The New Yorker:

Plus, the longer you stay on it the harder it becomes to stop. Prednisone is sometimes referred to as “the Devil’s Tic Tac”: cheap and available and effective, but at potentially scorching long-term costs.

Great term.

I always find it interesting that The New Yorker changes the titles of its stories for the internet so often. In print, this personal essay was titled “One of a Kind.”

// 01.26.23

For those who want to listen for almost an hour about PE in radiology, the current radiologist shortage, and navigating the job market, I was on the BackTable VIR podcast.

// 01.03.23

From the very pleasant small corner (seriously, just check out the comments!) of the internet that is author George Saunders’ substack, Story Club, answering a question about finding a mentor:

One of the things I’ve come to love about this Story Club community is its generosity. From where I sit, it feels like people show up here with the right attitude for any artistic endeavor, which is, “I bet there’s something for me to learn here.” This doesn’t mean that the person doesn’t already know quite a lot. But she has reverence for the importance and difficulty of the task and knows at some level that showing up in a curious, humble, friendly spirit, she’s more likely to return home with something of value.

If that’s not wisdom for approaching just about anything, I don’t know what is.

// 08.29.22

There is something to be said about a truly disastrous meal, a meal forever indelible in your memory because it’s so uniquely bad, it can only be deemed an achievement. The sort of meal where everyone involved was definitely trying to do something; it’s just not entirely clear what.

I’m not talking about a meal that’s poorly cooked, or a server who might be planning your murder—that sort of thing happens in the fat lump of the bell curve of bad. Instead, I’m talking about the long tail stuff – the sort of meals that make you feel as though the fabric of reality is unraveling. The ones that cause you to reassess the fundamentals of capitalism, and whether or not you’re living in a simulation in which someone failed to properly program this particular restaurant. The ones where you just know somebody’s going to lift a metal dome off a tray and reveal a single blue or red pill.

I’m talking about those meals.

This piece from The Everywhereist is perhaps the most enjoyable romp of a restaurant review since Peter Wells pilloried Guy Fieri’s Times Square restaurant back in 2012.

// 12.19.21

As we near the end of the residency interview season, a choice quotation from “Surely You’re Joking, Mr. Feynman!”: Adventures of a Curious Character:

So I have just one wish for you—the good luck to be somewhere where you are free to maintain the kind of integrity I have described, and where you do not feel forced by a need to maintain your position in the organization, or financial support, or so on, to lose your integrity. May you have that freedom.

// 01.18.21

From the original UK version of Adam Kay’s This is Going to Hurt: Secret Diaries of a Medical Resident:

Asked to review a patient in labour ward triage and repeat a PV as the midwife is uncertain of her findings. Her findings were of cephalic presentation with cervix 1 cm dilated. My findings are of breech presentation, cervix 6 cm dilated. I explain to mum that baby is bottom-down and the safest thing to do is to deliver by caesarean section. I don’t explain to mum which part of the baby the midwife has just stuck her finger in to 1 cm dilatation.

Good medical humor is rare.

// 01.14.21
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