I agreed to do a year-long monthly workforce column for AJR, and my first entry was published this week: It’s titled “A General Need” and contains my observations on the job market based on running Independent Radiology.
Miriam Pawel, in an op-ed in The New York Times, argues that the University of California should not bring back the SAT requirement for admission:
What has made the University of California exceptional is its commitment to increase access without sacrificing excellence. In recent years, California has proudly defied a national trend: On average, about 40 percent of its students are the first in their families to attend a four-year college. More than half qualify for free tuition. The percentages of underrepresented students have crept up, through a variety of initiatives. The California Dream Act gave undocumented students access to financial aid, as well as in-state tuition. Students on University of California campuses may struggle with basic math, but they are graduating at record rates.
That piece was largely in response to an opinion piece by UC Berkeley math professor Zvezdelina Stankova that made the rounds last month:
Without standardized tests, admissions officers are flying blind, especially as grade inflation has made transcripts a weaker indicator of readiness, and artificial intelligence has made admissions essays a weaker signal of students’ work.
All metrics are incomplete, and our general reliance on standardized tests has always been fraught. And yet, it’s also foolish to deny that standardized tests can be useful. I have to admit that Pawel’s argument seems to very obviously contradict itself: no sacrifice in quality and graduating at record rates but somehow still struggling with basic skills? I’m not sure that math checks out.
Apparently, it has been the desperate professors themselves who would like the SAT back and are being overruled. Pawel states:
“Yet just five years later, the University of California is embroiled again in a very public battle over whether to reinstate the SAT. Faculty members, whose 2020 recommendation to retain the test was overruled, have led the charge.”
The gap between administrators + pundits and people on the ground doing the actual work remains alive and well.
Even for students prepared for educational coursework, there is an additional problem: for many students, the degree is merely a credential that doesn’t necessarily reflect true learning or a practical skill acquisition. A medical student who wants to use the MD as a label for their startup bio has different goals than one who wants to be a practicing physician. Many students, in college and beyond, view their actual coursework as a partially unavoidable impediment to spending more time on their all-important extracurriculars that they think will provide the networking and resume-seasoning that will actually help them succeed.
We’ve confounded education as a learning process with “education” as credentialism, all while the costs go up and up and up. Grade inflation combined with CV-slop and the lack of helpful metrics erodes the value of a degree just as regular inflation makes money worth less over time. At some point, the value and the price become irreconcilable.
Yesterday was Yom Kippur, the Day of Repentance for Jews around the world and the end of the Days of Awe, an annual ten-day period of reflection and forgiveness. Rabbi David Wolpe:
Yom Kippur always recalls to my mind a poem written by a woman who was a member of the French Resistance in the 1940s and deported to Auschwitz. Her name was Charlotte Delbo, and she survived to write an account, Convoy to Auschwitz, as well as a trilogy about her experiences. There is a library in Paris today bearing her name. Delbo, who was not a Jew, wrote a poem, “Prayer to the Living to Forgive them for Being Alive.” The final lines of that poem in particular have become famous:
I beg you
do something
learn a dance step
something to justify your existence
something that gives you the right
to be dressed in your skin in your body hair
learn to walk and to laugh
because it would be too senseless
after all
for so many to have died
while you live
doing nothing with your life.[…]
Delbo’s poem and the prayers of Yom Kippur do not exhort us to achievement or performance. The message is not, “Life is short, and therefore you must diversify your portfolio.” Rather, “learn a dance step” suggests paying attention to the important simplicities of life, and being grateful for them. In a similar vein, Yom Kippur confronts us anew with the recognition that nothing is promised, no time is granted for certain, and what seems solid can dissolve in an instant. We and those we love are not here forever, and once our loved ones are gone we will long to again touch their faces and hear their voices.
During Rosh Hashanah and at the end of Yom Kippur, the piercing sound of the shofar serves as a wake-up call. Nothing is promised, so don’t waste the minutes. Love while there is time.
From Stop Pathologizing Normal Life, published this July in the NYTimes:
Which brings us to life’s meaning. The more meaningful that people find their lives, the more resilient they are when facing stress and the lower their risk of depression, anxiety, substance abuse and suicide.
Finding meaning is often characterized as a contemplative exercise, something arrived at through deep deliberation. But while our ability to turn inward and ponder existential questions makes humans unique in our quest for meaning, finding meaning tends to involve outward-oriented action. That’s because we feel the most meaningful when we are doing things that provide social significance — a sense that we matter, that we play an important role in other people’s lives.
Mattering matters. Easy placation has been the trend in education, with the blunting of tests, grades, etc. Later, a frictionless 100% remote life working bunker shifts hanging out with a computer all day is increasingly the demand from the workforce, including in my field of radiology.
How many people are selecting their day-to-day for significance and not just ease and convenience? Friction is frustrating, and yet, just as our muscles grow only when used, it seems like—amongst a substantial segment of society—our quest for control and smoothness may be removing a texture we didn’t know we needed.
Regarding a study of remote work looking at 500,000 Americans with “remotable jobs,” Prof Emma Harrington, one of the ‘Home Alone’ study’s authors:
When one person is out of the office, it impacts people who remain in the office, so even an on-site worker in a remotable job may now be lonelier because their colleagues choose to work from home.
They conclude that remote work “substantially increases isolation and worsens mental health.” The reality is assuredly varied and more complicated, but the impact of remote work on onsite work is, as suggested, pretty clear.
I have literally no association with the ABR, but since they’ve been gradually publishing more info about the new Oral Boards (coming to a computer near you in 2028) and not everyone reads The Beam newsletter as religiously as I do, I thought I’d share the goods in one spot here as well. Here’s what’s available so far:
1. Written Sample Case content, which walks you through a couple cases in each subspecialty: what you’re supposed to get from the presentation images, differentials, further imaging requests, and key features. Despite being written, this is very helpful.
2. 46 min “simulation” video (where an experienced radiologist playacts being an examinee). Contains 3 cases/attempts (a strong pass, a clear fail, and a marginal fail). To be clear, you can fail individual cases and still pass the exam. Overconfidence is a cardinal sin, and the clear fail is a parade of whiffs. One example contains a partial scrollable CT with some PACS tools. After the three cases, they re-perform them with the opposite performance/outcome.
3. A logistics guide PDF (no, you won’t be able to have a stand-in take the exam for you).
4. An FAQ, of course. One interesting tidbit: all MRI sequences will be labelled. They say:
The ABR Image Quality Committee and the Board of Trustees think that having candidates spend exam time identifying sequences would not add value to the exam experience. The rare exception might be a case where recognizing the specific sequence is the concept being tested (e.g., in-phase vs out-of-phase imaging in the abdomen, or “silicone-only” image on a breast implant study).
Something tells me there will be “rare” exceptions? (They also happened to include unlabeled MRI sequences in the video above.) I would also be totally unsurprised if nucs studies are still often presented as unknowns, even though that would also never happen in real life, but we’ll see.
5. The usual, generally unhelpful “study guide” (which lists the exam content including such profound hints as “pancreas” and “normal variants”).
6. A Scoring explanation:
Performance on an individual case is scored as 68, 69, 70, 71, or 72. Although a candidate does not need to pass every case to pass the category, the average of the case scores must equal or exceed 70 to pass the category. Hence, a candidate who is shown five cases and receives scores of 69, 70, 70, 70, and 71 would pass because the average of those scores is 70.
Those numbers (68-72) correspond to absolutely unsatisfactory, marginally unsatisfactory, satisfactory, good, and outstanding, respectively. In response to the scoring guide, I did reach out to the ABR to ask why the oral exam would be graded so…distinctively, instead of, say, 1-5 or some other more typical scale.
The answer:
First, “70” is often (but not universally) used as a passing threshold for high school and college exams, so it has an intuitive feel for a pass-fail test that is intended to measure competency rather than relative performance such as “excellence” or “perfection.”
Second, a 3 is “200%” better than a 1 (i.e. proportionally “large”). On the other end of the scale, a score of 5 on a case could be incorrectly understood to be “a lot better” than a 3. This is less an issue for a 70 vs a 72 although, as you imply, it’s mathematically the same result.
In re-introducing the DR Oral Exam, we’re sticking with the past model to avoid making too many changes as once, and to parallel the RO, MP, and IR scoring that has been in continuous use. All that said, I think we will consider going with the simpler version of 1-5 at some point in the future.
In other news, what’s old is new again.
From Stefan Zweig’s short book on the famous sixteenth-century Frenchman, a passage where Montaigne rales against schooling as the mere transmission of knowledge:
“They never cease whining into our ears,” he gripes, “as if it were being poured into a funnel, and our task is merely to parrot back everything we have been told.” Instead of allowing his own thoughts to ripen in his mind, the masters fill it with a petrified knowledge and leave it “bereft of insight and consciousness”. And he angrily contests: “What use is it to have a bellyful of meat, if one cannot digest it, if it cannot transform us, if it cannot improve us and fortify us?”
…
“As when plants suffocate for too much moisture, and lamps from too much oil, so the action of the spirit is suffocated by an overload of study and matter.” Such knowledge is a burden on the mind, not an action of the soul: “To know by heart is not to know, it is to keep what they have given you and store it in your memory.”
…
Therefore, later, the mature man will hand out a bad mark and a good lesson to those masters who only seek to inculcate rules mechanically: “our masters”, he says in his last years, should judge the aptitude of a child not by his memory but by the testimony of his life… Let the young man read and sift and verify, not just accept the authority in good faith. A rich variety of opinions must be presented to him. He will make his choice, and if he cannot, then he will remain in doubt. He who sheep-like follows another follows nothing. He discovers nothing, because he seeks nothing.
As Montaigne may have hoped, modern pedagogy has moved more toward flipped classrooms and discussion sections. After all, there is a difference between information and education. Interesting, though, is how the cheapening of readily accessible knowledge seems to have stunted educational growth. Perhaps a driven, precocious polymath may not have needed those strict guardrails of a rigid system, but inadequate groundwork and the lack of constraint also don’t seem to, well, work.
Undeniably:
Books are, I find, the best provisions a man can take with him on life’s journey.
Zweig happily points out that Montaigne, like Marcus Aurelius, was learning in public, not issuing decrees from a self-help pulpit:
It is true: Montaigne achieved little else in his life aside from posing the question: “How should I live?” But what is so magnificent, so philanthropic in his case, is that when he posed this question: “How should I live?” he did not insist on following it up with: “This is how you should live!”
…
He had never sought to counsel others on anything he did not know intimately himself. “This is not my doctrine; it is my study, and no one else’s lesson but my own.”
Possible false humility aside, admirable restraint.
Ordinary Abundance is a lovely little visual essay. Go ahead, feel good about human progress today.
From independent interventional radiologist Dr. Kavi Devulapalli’s recent article, “Coming to Terms With Reality“:
I can build a program that did not exist before I got there, develop the referral relationships, create the clinic, generate the patients, perform the procedures and produce millions of dollars of new facility economics. The hospital can measure that value, present it to a board, use it to justify investment and congratulate itself on the growth of the service line. When it comes time to figure out what I should be paid, however, we are suddenly talking about how many wRVUs I produced, what fair market value is for call coverage, how many hours I spent doing administrative work, what other employed IRs make and what percentile my compensation falls into.
This is why I increasingly describe the game as rigged. I don’t mean there is some guy at CMS sitting around trying to figure out how to personally ruin my life. What I mean is that once you understand how the pieces fit together, the result becomes pretty obvious. CMS separates the physician economics from the facility economics. The hospital owns the facility and employs the physician. The physician can then create tremendous additional enterprise value for the hospital, while Stark and AKS make it difficult to simply reconnect physician compensation to the downstream economics that physician helped create. Compensation gets pushed back toward the defensible value of physician labor, which is then informed in part by surveys of what other physicians operating inside the same system are being paid. If that doesn’t strike you as at least somewhat circular, I don’t know what to tell you.
Value has always been hard to define, but even if RVUs were a perfect measure of physician work in direct patient care, they would never, ever tell the complete story. The hospitals know this, even if they pretend not to during negotiations or their usual budgetary gerrymandering.