The month of August has been almost exclusively related to the usual activities of daily living and the new/growing job board I’ve started dedicated to true independent physician-owned radiology private practices, which now has 45 groups. I know a service like Independent Radiology probably has more impact than my usual sporadic writing, but I’m personally looking forward to getting back to my usual idiosyncrasies in September.
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.
More fun from Oliver Burkeman’s Four Thousand Weeks: Time Management for Mortals. In case you missed it, we started with happy nihilism through cosmic insignificance theory and acknowledging the trap of productivity.
More on that inescapable finitude:
And it means standing firm in the face of FOMO, the “fear of missing out,” because you come to realize that missing out on something—indeed, on almost everything—is basically guaranteed.
That cuts.
Time pressure comes largely from forces outside ourselves: from a cutthroat economy; from the loss of the social safety nets and family networks that used to help ease the burdens of work and childcare; and from the sexist expectation that women must excel in their careers while assuming most of the responsibilities at home. None of that will be solved by self-help alone; as the journalist Anne Helen Petersen writes in a widely shared essay on millennial burnout, you can’t fix such problems “with vacation, or an adult coloring book, or ‘anxiety baking,’ or the Pomodoro Technique, or overnight fucking oats.”
So long as you continue to respond to impossible demands on your time by trying to persuade yourself that you might one day find some way to do the impossible, you’re implicitly collaborating with those demands. Whereas once you deeply grasp that they are impossible, you’ll be newly empowered to resist them, and to focus instead on building the most meaningful life you can, in whatever situation you’re in.
I do like overnight oats though.
The more efficient you get, the more you become “a limitless reservoir for other people’s expectations,” in the words of the management expert Jim Benson.
“A limitless reservoir for other people’s expectations” is a great line.
As she recalls in her memoir The Iceberg, the British sculptor Marion Coutts was taking her two-year-old son to his first day with a new caregiver when her husband, the art critic Tom Lubbock, came to find her to tell her about the malignant brain tumor from which he was to die within three years:
Something has happened. A piece of news. We have had a diagnosis that has the status of an event. The news makes a rupture with what went before: clean, complete and total, save in one respect. It seems that after the event, the decision we make is to remain. Our [family] unit stands … We learn something. We are mortal. You might say you know this but you don’t. The news falls neatly between one moment and another. You would not think there was a gap for such a thing … It is as if a new physical law has been described for us bespoke: absolute as all the others are, yet terrifyingly casual. It is a law of perception. It says, You will lose everything that catches your eye.
Which is a devastating way to come to the realization.
And, finally, most importantly, JOMO:
The exhilaration that sometimes arises when you grasp this truth about finitude has been called the “joy of missing out,” by way of a deliberate contrast with the idea of the “fear of missing out.” It is the thrilling recognition that you wouldn’t even really want to be able to do everything, since if you didn’t have to decide what to miss out on, your choices couldn’t truly mean anything. In this state of mind, you can embrace the fact that you’re forgoing certain pleasures, or neglecting certain obligations, because whatever you’ve decided to do instead—earn money to support your family, write your novel, bathe the toddler, pause on a hiking trail to watch a pale winter sun sink below the horizon at dusk—is how you’ve chosen to spend a portion of time that you never had any right to expect.
From Paul Graham’s “The Right Kind of Stubborn:”
The persistent are attached to the goal. The obstinate are attached to their ideas about how to reach it.
Worse still, that means they’ll tend to be attached to their first ideas about how to solve a problem, even though these are the least informed by the experience of working on it. So the obstinate aren’t merely attached to details, but disproportionately likely to be attached to wrong ones.
I like this distinction.
In some ways, Graham’s distinction between persistence and obstinance feels analogous to experts and “experts” (or, perhaps more fairly, between continuous growth and brittle skill).
There are people for whom expertise is partially a mindset: they question assumptions, their approach, and their knowledge. They want to be challenged, and they want to learn, and they want to improve.
And then there are those for whom expertise is a status. Their identity is tied to having the answers, and they know the right way to do things.
It’s a bit of a false dichotomy. People can be both obstinate and persistent in different contexts.
But if you’re overly rigid in your work or competing approaches feel like threats, you’re probably being too precious. Your excuse for doing things a certain way in the face of better alternatives probably shouldn’t be “It’s the way I learned how to do it,” or “That’s the way I’ve always done it.”
5 years into running a small one-physician psychiatry private practice, my wife’s EMR/EHR, Luminello, sold to private equity and was shut down to force its users to transfer to its new owner, SimplePractice. The whole experience was so shady that she was forced to survey the market and pick a new EHR. So she did.
(This post is mostly written by her in the first person. You also might enjoy our last post about how to start a psychiatry private practice.)
Introduction
Disability Insurance is a boring and expensive but critical component of a physician’s financial plan.
While life insurance pays your beneficiaries when you die, disability insurance pays you when you can’t work due to a medical condition. It insures your most valuable asset: your future earnings potential in a profession after you spent years investing in yourself.
Upfront Summary
- Disability insurance helps you pay for your life (and lifestyle) when you can’t work.
- You (ideally) want an individual, portable, noncancelable, guaranteed-renewable, true own-occupation specialty-specific policy.
- You want that policy as soon as you can afford one, and you want to include at least a few “riders” (options).
- One is a “future benefit increase” option or equivalent phrasing, which will let you buy more insurance as your income increases without needing to undergo additional medical underwriting.
- Also important is a “partial” or “residual” disability rider, that will pay you if your income falls because you can’t work full-time or perform certain tasks (e.g. a surgeon who can’t operate to make their full income but can still see patients in clinic).
- Another is a “cost of living adjustment” (COLA) rider, which will help mitigate inflation.
- You’ll want a big enough policy benefit to help prevent a lifestyle shock should you become disabled while also still being able to save enough for old age (“retirement”), since the policy you choose will likely stop paying benefits around age 65.
- The whole thing will probably cost more than you will enjoy paying, but you’ll always have the option to cancel the policy whenever you want once you’re financially secure and don’t need the benefits.
- Before you get that magical policy, you may want to lock in some basal coverage by securing a Guaranteed-Standard Issue (GSI) policy first, which doesn’t require medical underwriting (see below).
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.
An interesting essay by Leopold Aschenbrenner discussing the recent history of as well predictions for the next 10 years of AI: “From GPT-4 to AGI”
A long but good read, which itself is part of an even longer series.
Forget about AI taking your job, maybe we’ll all just live forever.
From “Writer Math” by Elissa Bassist in McSweeney’s:
If you think a piece is 100 percent done, it’s actually 45 percent done. To get it to 100 percent done, you can’t.