ABR OLA MOC: The First-Year Experience

2019 was the initial offering of ABR’s MOC of the future: Online Longitudinal Assessment (OLA). I wrote about it earlier this year, but to recap: All Diagnostic Radiology ABR diplomates including those fresh off their Certifying Exam victory lap were immediately thrust into the new paradigm. This amounts to answering a whopping 52 multiple choice questions over the course of the calendar year in whatever subspecialty composition you prefer. Questions are released 2 per week and expire after a month.

It’s…fine? Sorta I guess?

The website works (mostly), and the questions are questions (undeniable). Some are pretty good, some certainly less so. People on the internet grumble about content relevance more than I personally would, but then again the minute I got a lame low-yield Core-style GI fluoro question I switched to 100% neuroradiology.

The ABR hasn’t released the passing thresholds yet, which is the most interesting facet of the whole ordeal: recall that the Core and Certifying Exams are “criterion-referenced” by magical Angoff committees that can infallibly determine what a “minimally component” radiologist can do. The ABR just doesn’t seem to have that same confidence when it comes to MOC, presumably because they have no idea how many people would fail if they had logically employed that exact same Angoff method, and failing an unknown number of already dissenting practicing radiologists is a much bigger deal than embarrassing some more trainees.

Now before you say that each diplomate needs to hit 200+ questions to hit the psychometric validity threshold, the ABR could still tell people if they were on track to pass or fail based on their current performance. There are apparently plans to release preliminary feedback soon (which may do just that now that there is some real-world data to calibrate with), but all of us will need to do another few years of OLA to learn if we’re truly maintaining the magic.

In case you were wondering, I did get one question wrong (the software buries additional images in tabs you have to click through; I kept forgetting, though it only burned me the one time).


There are no secrets as to why the ABR chose to release two questions per week that subsequently expire a month later. I finished my required questions in August, less than a year from when I took (and presumably destroyed) the Certifying Exam (but we’ll never know because they don’t release scores for that exam).

What I can tell you is that I spent approximately one hour satisfying the OLA requirements for the year. Without the forced drip-feeding, I could’ve accomplished the entire process during a single generous lunch break.

Some of you reading may be thinking, hey, that’s not so bad. And you’re right, the process is relatively painless. I didn’t learn anything, but at least it didn’t take a lot of my time.

Ultimately, that’s also what makes MOC a meaningless box-checking endeavor and blatant money grab.

The argument that something isn’t stupid, bad, useless, or wrongheaded as long as it doesn’t suck is spurious. Just because it could be worse doesn’t mean that it shouldn’t be better.

And the fact that many doctors are scared that these unelected unaccountable pseudo-governing organizations will punish any dissent by making tests harder and MOC more arduous is toxic and should not be accepted. We shouldn’t treat the relative ease of a profit-seeking exercise as a thrown bone from the shadow lords that can be taken away at any time or a secret to keep quiet so the “public” doesn’t find out.

The Anti-MOC Wave

I am actually not really part of the large and growing cohort of physicians adamantly opposed to any third-party validation of demonstrable skill or the mere idea of a certification-granting organization that can reliably establish minimal competence. In fact, if board certification wasn’t a de facto requirement in many contexts (and thus akin to licensure itself), I wouldn’t even mind if the supposed threshold was greater than minimal competence.

The ABMS was founded in 1933. The ABR was founded in 1934. We’re still waiting on evidence that anything these people do means anything. If the intellectual underpinnings of initial certification are up for debate, then the “maintenance” of said certification is doubly so (hence the lawsuit).

The new system may be no worse than the 10-year exam it replaced; it would seem to me that it’s likely significantly less hassle. Less studying, less travel, less time, less effort, and more relevant (in that you can exclude broad categories of radiology irrelevant to your practice). However, cumbersomeness (or lack thereof) is not a component of psychometric validity.

A lack of rigor may serve as a salve for diplomates injured by losing out on years of rightfully-earned respite after a recently passed 10-year exam, but it doesn’t change the fact that gradually adding strata of multiple-choice questions on a foundation of more multiple-choice questions creates a weak structure that teeters in the winds of change.

PSLF is also a partial federal match for pretax retirement contributions

For those who qualify, PSLF can make an incredible difference in your long-term financial health by wiping away your student loans well before and for less money then you may be able to accomplish for yourself.

Due to the way income-driven repayment plan monthly payments are calculated, PSLF also acts as a government subsidy on your pretax retirement contributions. If you are currently using an income-driven repayment plan, every dollar you contribute this year to a pretax account will not only save you money on taxes this year (at your marginal tax rate) but will also “lower” your income for the year and then save you ten cents the following year.


Because IDR loan payments are calculated according to your discretionary income. Less income, smaller payments. For the two most common plans for recent borrowers, PAYE and REPAYE, it’s 10% (for borrowers on the old version of IBR, 15%).

For loans eventually forgiven via the PSLF program, every single dollar less you spend on your loans during the 10 years of repayment is another dollar that you save. This amounts to a partial federal match on your 401(k)/403(b)/traditional IRA contributions and an automatic 10% return on your investment.

Theoretically, the relatively low income of a resident is generally ideal for making post-tax Roth contributions (either to a Roth 401(k)/403(b) or Roth IRA). This is because doctors are felt to likely want to retire on more annual “income” than they earn as a resident, so that paying taxes now in a lower bracket is better than paying taxes later when in a higher bracket (not to mention the possibility that tax brackets may be higher across the board in the future). That said, a life in retirement without constant car payments, a mortgage, or student loans would cost far less than a similar lifestyle as a young professional. The bonus “match” is a reason to consider making pretax contributions against the more conventional wisdom.

Note that even without PSLF, pretax contributions still reduce monthly payments. For people actually paying off their loans, lower payments generally aren’t a good thing (just more money spent in the long term on interest), but in the setting of REPAYE and negative amortization, the lower payments would also mean more unpaid interest and thus more unpaid interest waived via the 50% unpaid interest subsidy and a lower effective interest rate.

For example, if you were somehow able to max out your personal contribution ($19,000 in 2019), then you would reduce your payments by $1,900 the following year in PAYE/REPAYE (or $2850 in IBR). That’s $158 per month. And that kind of savings over 10 years definitely adds up.

Extending $0 payments

Things can get really creative. If you were lucky enough to have a working spouse who earns enough to pay for your family’s living expenses (or are so hyper frugal that you live in the call room and eat saltine crackers pilfered from the ER for the majority of your meals), you could even pull a clever trick and zero out your loan payments for your first two years of residency. How?

Well, if you read my beloved (free) book, this helpful post about consolidating your loans after graduation, or remember the bit about this from a few paragraphs ago, you’d recall that payments under an IDR plan are calculated as 10% of your discretionary income based on last year‘s taxes under PAYE/REPAYE. A graduating medical student / new intern generally made little to no money the prior year and can secure zero dollar monthly payments for their intern year that nonetheless still qualify for PSLF.

Now here is where the retirement contribution component comes in. Normally, a second-year resident who consolidated after graduation will make payments based on a tax return that combines the last half of their fourth year of medical school and the first half of their internship. This means that it essentially based on a half year of income, say $25-30k instead of $50-60k.

Discretionary income takes your adjusted gross income and subtracts 150% of the poverty line. So PAYE = 10% (AGI – 150% x Poverty Line) / 12. For example, in the contiguous 48 states in 2019, the poverty line for a single person is $12,490. As a practical matter, this means that a single borrower must make around $19k per year in order to have a non-zero payment. Therefore, if you can put away enough money in the first half of your intern year to reduce your gross income to the poverty line, then your payments the following year will also be zero dollars.

(Note: it’s actually probably better to have a token payment of a few dollars so that there is an easier paper trail of payments for PSLF as well as no chance of your servicer not applying the 0.25% interest rate reduction for setting up auto-pay).

Roth conversions can be a useful hedge

Consider a Roth conversion to be a hedge. Now if a light bulb just went off and you’re thinking you could place money in a pretax 403b/401k to get the income-lowering benefits for IDR/PSLF purposes and then immediately convert that money to Roth in order to take long-term advantage of their low current income bracket, that’s not how it works. The IRS treats the Roth conversion amount as income for your taxes, so it undoes the income lowering.

But while in REPAYE, you could make pretax contributions during your early residency years as we discussed to get the lowest effective rate possible. Then, during your final training year—if you now know you’re not going for PSLF and have enough money saved up—do a Roth conversion and pay the taxes at your low resident income bracket before you become an attending. A senior resident and an intern are in the same tax bracket unless a lot of moonlighting is taking place, so you don’t lose money that way due to higher marginal taxes. In this setting, you’d likely follow this with a student loan private refinance, so the increased AGI for the following year wouldn’t matter.

Take Home

So, in addition to providing uncapped tax-free loan forgiveness, don’t forget that PSLF also functions as a government subsidy on your retirement accounts as well.

Academic Medicine and the Peter Principle

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

The Three-legged Stool

Academic medicine is sometimes described as a three-legged stool, where the department/institution is balanced on the three pillars of clinical care, research, and education. There is a pervasive myth that academic physicians can do it all: be an outstanding clinician, an excellent teacher, and a prodigious researcher. The reality is that most people don’t have all three skills in sufficient measure, and even those that do are not given the requisite time to perform meaningfully in all three categories.

While polymaths exist, the idea of the physician-scientist is increasingly intractable in modern medicine. The demands of clinical work have increased substantially with increasingly advanced medicine, increased productivity/RVU expectations, often overwhelming documentation burdens, and greater trainee oversight. Meanwhile, research has gotten more complex at the same time that the grant money has dried up. More and more of the funding pie goes to fewer and fewer people. And, lastly, education is typically taken for granted as something that should just take care of itself, something we expect “clinician educators” to do without faculty development, dedicated time, or even credit.

It’s very easy to have an unbalanced stool. Departments tend to lean in one direction or another precisely because they are aligned to do so and are staffed accordingly. As Arthur Jones of Proctor & Gamble famously remarked, “All organizations are perfectly designed to get the results they get.”

Putting pressure on individuals to do everything—deliver excellent clinical care, teach/mentor students/trainees, and contribute to high-impact research—fails to acknowledge the reality on the ground that doing high-end work in any of these dimensions is hard. Without dedicated time and sufficient support, doing anything successfully for very long is a challenge. Trying to work toward impossible expectations (even self-imposed ones) is a big contributor to burnout. At least a veneer of control, self-determination, and respect are prerequisites–not luxuries–for a successful “knowledge worker”-type career. We could more reasonably expect people in every role to excel at one role, be competent at another, and largely ignore the third.

Hospitals and large academic institutions are not filled by flat teams of equals working on a common mission, they are occupied by layers of committees and bureaucracy. Rising stars often contribute more to their superior’s careers than their own. Progress, change, and new initiatives are choked by a spinning-wheels-grind of proposals, SOPs, committees (and subcommittees), amassing nebulous “stakeholders,” and every other trick in the large organization toolbox that isn’t bad in theory but should never be implemented universally and thoughtlessly. It’s all leadership in the I-attended-a-leadership-conference sense without any true leadership.

Physicians who focus on producing excellent care are derided as “worker bees” while those who believe in education are labeled “doesn’t like research.” And the managers rise to the level of their incompetence and perpetuate the hierarchy.

Meanwhile, the consultants and nonphysician leadership consolidate power outside of the traditional hierarchy. And how can we stop them, when we do such a bad job ourselves?

Talking to Strangers & Professional Identity

From this NYTimes’ interview with Malcolm Gladwell about his new book, Talking to Strangers:

“That happens in these divided times — your professional identity becomes your identity,” Mr. Gladwell said.

“On every level,” he added, “I feel like there is this weird disconnect between the way the world is presented to us in the media and the way it really is. The goal is simply to give people an opportunity to reflect on things they otherwise wouldn’t reflect on. What they do next is out of my control.”

When people ask me about AI and radiology or automation in general, I tend to take an Amara’s Law view: We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.

But the short term overhype is our best chance to make thoughtful structural changes that will allow for desirable future outcomes. A lot of mental health and structural economic problems are tied up in Gladwell’s first line:

If your professional identity is your identity, what happens when you or your profession need to change? If the individuals you meet are just proxies for the job they do or the service they provide, then they aren’t people to you.

A Deep Dive into the Tax Returns of the American Board of Radiology

With the class-action antitrust suit filed against the ABR earlier this year, a post looking deeper at the finances that make an appearance in the lawsuit is overdue. You can find the recent filings that I used for this post collected here.

I promise this is a more interesting read than one might think.


The ABR is a 501(c)(6) organization.

Readers may be familiar with the more common 501(c)(3) designation, which is the non-profit status used by religious, charitable, scientific, and educational organizations (and is the type generally required to qualify for loan forgiveness within the Public Service Loan Forgiveness (PSLF) program).

A 501(c)(6) organization is a business league or association organized and operated primarily to “promote the common business interests of its members.” I’m not really sure how the ABR qualifies as that, but it’s a self-reported designation and that’s their purpose as far as the IRS is concerned. (burn!)

Regardless, as a tax-exempt non-profit, the ABR must make public their Form 990 annual returns for the past three years. The most recent returns (2017 tax year, filed in 2018) are also available on several sites including ProPublica and GuideStar, both of which maintain a searchable database of all non-profit tax returns.

But before we go through the returns and try to make sense of the ABR’s finances, a disclaimer: I am a radiologist with a hobbyist understanding of the tax code, not a CPA, tax preparer, or financial anything (let alone a forensic accountant). This is all for entertainment purposes only.

Disclaimer #2: Form 990 is light on details. I emailed the ABR for clarifications about several issues. Unsurprisingly, they ignored me.

Revenue Breakdown

Tax-exempt non-profits can, in fact, have taxable income if the income derives from activities separate from their mission. In 2016, the ABR claimed $45,605 in taxable income on line 7. In Part VIII, this was described as real estate rental income. I don’t know what they’re renting or to whom they rent to. In 2017, it was down to around $30k.

Total tax-exempt revenue is mostly from “certification fees.” Over the past five years, total revenue (which includes investment income):

2017: $17,430,259 (up $1,138,815, 6.9%)
2016: $16,291,444 (up $530,424, 3.4%)
2015: $15,761,020 (up $585,430, 3.9%)
2014: $15,175,589 (up $1,635,419, 12.1%)
2013: $13,540,170

For reference, the inflation rates over this period according to the US Labor Department were 0.8% in 2014, 0.7% in 2015, 2.1% in 2016, and 2.1% in 2017. So the ABR has reported true growing revenue.

Though not specified as such in the 990, the substantial year over year increase is primarily related to increasing MOC enrollment.

In 2017’s Part III, the ABR says that it administered 4,790 total exams and that approximately 27,000 diplomates were enrolled in MOC. As a reminder, MOC costs $340/year, so the revenue from MOC was approximately $9.2 million in 2017. Note that because older radiologists were grandfathered with “Lifetime” certifications whereas all new diplomates immediately enter MOC, this number will enlarge annually until a steady state is reached, presumably sometime in the next 10-20 years. I’m sure the ABR has a better idea of when the gravy train will hit its coasting speed.

To wit, the number of MOC-enrolled physicians was 26,140 in 2016, 25,000 in 2015, and 24,000 in 2014. With over a thousand new diplomates automatically enrolled in MOC every year, the ABR can anticipate rising revenue for the foreseeable future.

Also note that MOC revenue scales fantastically, as the incremental cost to service an individual enrollee approaches $0 but each one brings in $340 every year throughout their career.

Subtracting MOC income from the total fee-related revenue of $16,271,311 would leave around $7 million in revenue from exam services ($7.4MM in 2016). As I’ve discussed before, around $3 million of that comes just from residents, who spend around 1% of their pre-tax income directly to the ABR annually without exception.

In the 2018 annual report, ABR president Brent Wagner made this comment on the first page of content:

As a non-for-profit, the ABR collects fees to cover the expenses of administering the programs. Reserves are maintained to cover unexpected capital expenses, but fees are set as closely as possible to approximate administrative expenses.

Based on the numbers you just read, I think you can see where this is going. But let’s see how that holds up.


Expenses also continued to rise from $13,758,299 in 2015 to $15,590,929 (a 13% increase) in 2016 to $16,468,080 in 2017 (a 5.6% increase). Payroll-type expenses increased from $6,932,139 to $7,342,360 (a 6% increase) to $8,256,080 (a 12% increase).

Revenue minus expenses yield a “non” profit of $962,179 in 2017, down from $1,329,124 in 2016.

So despite $17.4MM in revenue, the ABR claims its expenses take out all but a single mil. Let’s look at some of those.


We don’t need to name names of every ABR officer and their compensation, but we can at least track the highest paid, who is Dr. Valerie Jackson, the ABR’s executive director during the studied period.

YearSalaryNon-salary (retirement + benefits)Total Compensation

2015 was a good year to hold the reins.

These numbers are interesting in how they may or may not correlate with the recent changes to the ABR board certification process that occurred in 2013 as well as the rising profits from MOC endeavors (common among ABMS members) and then perhaps coincidentally followed by small token decreases in light of increasing physician frustration with MOC across the country, increased scrutiny of member-board financials (like these wonderful reads from Newsweek about the ABIM), or the recent series of class action lawsuits.

Or that could totally be a coincidence. What any reader can agree on is that being the head of the ABR is certainly a livable income.

Another reason payroll increased? In 2017, the ABR hired a “Director of External Relations” whose base salary is $135,033. Trying to make the ABR look good is apparently a challenging full-time task. To round out the A-Team, they also hired a similarly paid “IT Director” (possibly as a result of Mammogeddon) and a “Managing Director,” to, um, manage and direct things?

“Other” Expenses

Other expenses make up the majority of the ABRs expenses and totaled $8,248,569. What are “other” expenses you ask? Look no further than Part IX (“Statement of Functional Expenses”)

These include things like credit card processing fees, office expenses, insurance, etc. I wouldn’t pretend to have any idea about how much the ABR should spend on staplers and toner.

Expenses are hard to parse because they’re grouped into large nebulous categories.

  • In 2016, the ABR spent $2,204,166 for Exam Services. Given that the ABR owns its own testing center, the exams are administered by employees, and the questions are largely written by volunteers, I would personally be interested in having these big numbers broken down some more. In 2017, this dropped down to $466,472.
  • $1,292,317 was for conferences, conventions, and meetings. The ABR does reportedly convalesce in Hawaii twice annually. This is down from $1,534,608 in 2016.
  • Legal services accounted for $45,439 in 2017. Watch for that number to rise substantially in 2019.
  • $1,051,695 was for “Other fees” — who knows? These are often payments made to various independent contractors that don’t fall into the other categories likes investment management fees, IT, etc.
  • Another mil for office expenses. Another mil for occupancy (rent, utilities, real estate taxes, etc).
  • And a big $5.4MM for salaries/wages of the nonexecutive rank and file.

What we do know from Schedule J, which details compensation information, is that the ABR does “reimburse board members for companion’s travel.” That’s probably in the $640,464 figure for travel, which is separate from the $1.3MM above for conferences/meetings. Twice annual all-expense-paid trips for the family to Hawaii do sound nice.

The ABR doesn’t run lean.

War Chest

Rising revenues have nicely padded the ABR’s current assets, which totaled $51,737,127 in 2017, up from $49.5 million in 2016 and $45.7 million in 2015.

The ABR does claim $10.8MM in liabilities, so according to its 990, the net assets total $40.8MM. However, these liabilities include $8,914,139 in “deferred revenue.” This is to say, the lower figure is meaningless in a common-sense interpretation. Deferred revenue is a mostly BS accounting technique used to refer to payments made in advance for services not yet rendered. In this case, it’s a convenient way to make it look like you’re making less money than you really are. Based on the figure, it would seem the ABR jams all the MOC fees in there, though it’s not as though they offer refunds.

In everyday terms, most would argue that all of the ABR’s revenue is “unearned.” Regardless, outside of clever spreadsheets, that cash isn’t really a liability. It’s all sitting in the bank.

So, the ABR was really holding on to a war chest of almost $52 million in 2017.

Even with questionable payroll, staffing, and vacation meeting practices, the ABR still has an annual operating revenue surplus (aka a profit) of a million bucks. What size of “reserves” will finally be sufficient to “cover unexpected capital expenses,” so to speak? Maybe the slush fund was to cover the inevitable lawsuit. Outside of its testing business, the ABR investment portfolio itself gained almost a million in 2017 and almost two million in 2016.

Even if the ABR stopped making a profit on fees (hard to do even with an impressive meeting budget), they would still likely make money every year. The portfolio proceeds would certainly be enough, for example, to drop the resident and fellow fees down to attending levels from their current $300 premium ($640/yr for trainees vs $340/yr for MOC).

The ABR Foundation

The ABR does maintain a separate “Foundation” that is a 501(c)3 organization. The ABR Foundation, unlike the ABR, is able to receive tax-exempt charitable donations. The nebulous purpose of the ABR Foundation is “to demonstrate, enhance, and continuously improve accountability to the public in the use of medical imaging and radiation therapy.” Like you, dear reader, I have no idea what that means.

Later, the mission of the foundation is described: “The Foundation carries out the scientific, educational and charitable purpose of the mission of the American Board of Radiology.” I have a hard time picturing that too. The final description of the mission: “to demonstrate, enhance, and continuously improve accountability to the public in the use of medical imaging and radiation therapy.” Darn, that still doesn’t help.

In 2017, it only made money from investments on its net assets (now $1.6MM). No one gave them any money, and they awarded no new grants. Why?

Because, since 2015:
“The Foundation is re-evaluating program services offered to determine how to most effectively achieve the mission statement. During this period of re-evaluation, no new contributions are currently being accepted. Current program commitments for sponsorships continue to be serviced.”

In 2014, the ABR awarded two grants:
1. $95,000 to create a national brachytherapy registry and QA program
2. $25,550 to create ethics and professionalism instructional modules

But 2013 was a much more interesting year:
The ABR Foundation somehow managed to receive $202,348. Total expenses were $305,982:
1. $95k again went to the brachytherapy project
2. $77,599 went to “summit meetings/conduct symposiums to optimize a national strategy for safe and appropriate medical imaging”
3. An additional $115,908 were also “meetings expenses”

So, it’s meetings all the way down.

Either way, the foundation seems mostly defunct now.

American Board of Radiology International

Is a “disregarded entity” that made $178,750 for total assets $539,649 in 2016. Its stated purpose is to “provide guidance in a radiology certification exam program.” Yes, a program. I have no idea.




So to summarize, I am not an accountant. If you or someone you love has more information about the ABR’s operations or financial workings, please feel free to contact me. I would love to update this post (or all my posts, for that matter). I feel strongly that there should be more information available to candidates and diplomates, and it would be much better if it came unwhitewashed from the ABR itself rather than from someone throwing snarky potshots from the sidelines like myself.

The ABR makes a lot of money from trainees and radiologists who have zero say in its operations and to whom the ABR does not feel accountable.

The ABR’s expenses are hard to parse but are clearly not super-duper efficient in their use of very generous certification fees.

The war chest was around $52 million in 2017, is almost certainly higher now, and will continue increasing every year for the foreseeable future due to essentially compulsory MOC.

Assuming any of the current lawsuits progress to discovery and aren’t confidentially settled, we can eventually expect some fascinating news in the years to come. In the meantime, those legal fees certainly aren’t going to help their bottom line.