Ben White

What Makes a Radiologist Feel Special?

09.15.25 // Radiology

Not all radiology jobs are created equal in part because not all radiologists with the same job are treated equally. In a field divided between democratic groups, corporate employers, and academic institutions, the meaning of fairness and the value of “specialness” vary wildly.

Compensation, autonomy, and respect are all on the table.

For different kinds of radiology jobs, there are different kinds of radiologists.

The Democratic “Ideal”

One thing about any traditional private practice is that, in most cases, all partners are equal. They share in the work and share in the profits. Typically, any differences in compensation—if there are any—are a reflection of differing schedules (like buying and selling of weekend call shifts or vacation) or a reflection of a productivity incentive component, where the radiologist earns additional income for RVUs generated in excess of some predetermined benchmark (because while pay is often equal, production often is not). An external entity can help support necessary admin time through stipends/directorships, but this usually comes from outside of the practice.

If things aren’t fair and transparent, something is wrong.

When Someone Else Holds the Keys

Radiologists working for a third party—like a PE-owned entity or a hospital/university medical center—are in a different situation.

Obviously, in some cases, people can be paid and valued similarly. But a third party holding the keys creates more opportunity for sweetheart deals and special treatment.

This isn’t a knock on those models, because ultimately while flexibility can be used poorly—by undervaluing people, rewarding friends, or exploting those who don’t negotiate—it can also be a powerful business tool (for “good”?) in the sense that you can flexibly pay what the market demands for a given in-demand skill set, even if it doesn’t seem “fair.”

If you’re trying to grow a service line (or keep one on life support) and you need someone with specific skills, you can choose to invest in that person in a way that can be challenging, if not impossible, in a democratic group.

In a world where some radiologists are attempting to optimize for $/RVU, we shouldn’t pretend that democracy always works or that “fairness” always feels fair.

In my practice, a 20-year veteran doesn’t make more for the same work as a new partner. In the academic center I trained at, some senior physicians earned more while doing less.

Now, for those special radiologists who are in demand (like breast imagers in recent years), the current shortage has again enabled a lot of offers—sometimes with high compensation or cush schedules available even for remote work—for the right kind of person for the right kind of job.

What may feel arbitrary or unfair may just be a necessary, intentional response to market forces in order to avoid operational insolvency.

Merit & Loyalty

There is also an important distinction between loyalty to an institution or a platonic ideal, loyalty to a deserving person, or nepotism. The classic academic notion of paying your dues and enjoying better pay with more respect and a better schedule merely through seniority is perhaps not the best way to create a well-functioning meritocratic enterprise.

Academic radiologists need to believe in both the mission and the institution to invest over the long term. Rapid turnover, bad governance, and obvious disparities can easily sabotage what should be the strongest cultures in healthcare.

I once knew an outstanding attending who left their institution because the new junior faculty (including some she helped train) were getting a better deal, including higher compensation. The market had moved, but the institution wasn’t willing to revisit established faculty salaries. The department isn’t a democracy, but this radiologist was worth more by all metrics.

If the academy can’t figure out how to balance specialness with fairness, it’s going to continue to exist in a no-man’s land between democratic private practice and commodified but well-paying corporate work. Many doctors have figured out that the institution often doesn’t love you back.

Rational Actors, Systemic Consequences?

What is best for the individual in the short term may be at odds with what is best for the community in the short term and/or the field in the long term.

This is just another reflection of the tragedy of the radiology commons that plagues all sectors of healthcare:

Those individual choices are logical. The “right” move having downstream effects doesn’t make it a bad choice, especially if the negative consequences are hypothetical or only occur if others pile on (and even then over a long time horizon); that’s why it’s called a tragedy: it’s mostly reasonable people doing reasonable things. Whether those individuals will find that their new opportunities are worth it—or live up to the anticipation—is, of course, unknowable.

Assuredly, sometimes they do. The radiology gig economy is growing precisely because there are a lot of people optimizing for compensation-per-effort and/or flexibility, and some are clearly very satisfied.

But, sometimes, the reality doesn’t quite live up to the expectation. Certainly, some groups that sold to RP over the past decade have regretted the decision. And I see no reason to assume that trends toward commodified pay-per-widget work in a consolidated world will lead to maximum radiologist utility over a long-term time horizon.

Rates per RVU are awesome—but only when they’re high. In the long run, commodification doesn’t care how special you used to be.

The Failed Experiment of Low Expectations

09.11.25 // Medicine, Miscellany

From “The Perverse Consequences of the Easy A,” published last month in The Atlantic:

When everyone gets an A, an A starts to mean very little. The kind of student that gets admitted to Harvard (or any elite college) wants to compete. They’ve spent their lives clawing upward. Khurana, the former dean, observed that Harvard students want success to feel meaningful. Getting all A’s is necessary, but insufficient.

This has created what Claybaugh called a “shadow system of distinction.” Students now use extracurriculars to differentiate themselves from their peers.

I also cared more about extracurriculars than classes when I was in college, and I graduated back in 2008. Part of it was that the classes were often not all that great and the other stuff was fun, but—

The parallels to pass/fail Step 1 and pass/fail medical schools are obvious. I don’t work with enough students to know if the proposed psychological benefits entirely failed to materialize—certainly the world is complicated and students are wrestling with broader societal trends, the Covid aftermath, social media despair, etc—but the impact on CV buffing is undeniable.

Medical school hasn’t changed all that much over the past century, but it seems like the recent drift in the status quo also isn’t really working?

But even at Harvard, change won’t be easy:

Now that they know that making college easier doesn’t reduce stress, Harvard administrators are attempting to rediscover a morsel of lost wisdom from the ancient past: School should be about academics. In March, the faculty amended the student handbook to emphasize the highly novel point that students should prioritize their schoolwork.

The Residency Selection Research Arms Race

09.08.25 // Medicine

Laws of unintended consequences combined with a crappy system, this can’t be the right way for people to spend their time collecting brownie points:

(chart via NRMP’s Charting Outcomes)

(I apparently shared a similar but different chart a couple of years ago as well.)

The prevailing belief is that in the era of pass/fail Step 1, students need to compete on research to stand out. I think that is probably not quite the reality, as we still have a measurable Step 2. I think we’re really seeing is not the need to stand out because of P/F Step 1 but rather the combination of relatively increased available time and greater uncertainty:

Time & Pressure:

With the pressure of Step 1 removed for strong students (who are in no danger of failing), pass/fail Step 1 has enabled many students to spend more time generally polishing their applications. This has been compounded by pass/fail curricula more broadly. Learning enough to pass simply doesn’t take the same amount of time as aiming for a perfect score.

Research is typically felt to be “more important” than other extracurriculars and it’s easy to quantify, but people are also certainly also checking boxes for volunteer opportunities and clubs. Everyone seems to have been 1 of 4 co-presidents of their local Magical Interest Group.

Schools went pass/fail for a variety of good reasons, but nature abhors a vacuum. It’s been filled with measurable trash.

Uncertainty:

We already had our longstanding competition due to the scarcity of “desirable” residency spots, but other unintended consequence of all these pass/fail components is that it delays knowing how competitive you really are for your desired field.

It used to be that you received a disappointing score on Step 1, and—before clerkships even started—you adjusted your dreams of dermatology.

Now that you can’t know if your Step 2 score will be competitive until you’ve already essentially entered application season. It makes intuitive sense to do everything else in your power to polish your potential turd if you want to maximize your chances for your desired specialty + location combination.

Step 2 is the new Step 1; it’s just harder to plan a career around.

So what?

Reasonableness at the n=1 level aside, I think this is a problem.

The research slop is largely meaningless. The work itself is mostly garbage, and people are wasting time, money, and resources filling the dregs of pay-to-publish journals. We’re also incentivizing volume over quality so that students are incentivized to pretend that random surveys and opinion pieces are research instead of spending real time doing real work that could have a meaningful impact on other people or actually develop valuable skills. Most work is read by no one except AI bots, and the last thing we need are the LLMs internalizing a bunch more fake research and observational BS.

Time is zero-sum. The question can therefore never just be: is there value? Despite the mockery and dismissal above, of course there is some value. The question has to be: is this the best use of limited resources to achieve the goals of graduating good doctors?

Building a true meritocracy with holistic application selection is an incredible challenge. Matching people to a limited prospective jobs based on both their desires and their aptitudes is truly hard, and the desperation to shine is just as reasonable here as high school students buffing their resumes for college admissions.

Easy Mitigation Steps

We can’t change the overall game, but we can adjust the rules to nudge the behaviors to our desired outcomes.

The NRMP needs to at least start reporting the median and not the mean. Even better, we should split application success into quartiles. Students currently see this data and are mislead, because long tail outliers are dragging the mean up. Many who are “below average” for their field aren’t actually below the median. Break these things down by quartile and maybe then we’ll see how “required” and impactful research really is in most fields.

We should probably also limit the ERAS length and separate posters/abstracts/presentations from publications. We need to limit the double-counting that distorts the averages and change the incentives to promote diving deep to do meaningful work.

The Great Filter

After posting that chart and out of curiosity, I did a 100% unscientific poll on Twitter with 71 responses:

 

So, I can’t pretend that the students are wrong to play the game. It just means even more that, as a field, we need to adjust our systems and incentives to drive our actual desired behavior and improve our actual observable outcomes.

Of course, how widespread this type of filtering really is and the actual impact for different specialities would make for a great research project.

“For many big life choices, we only learn what we need to know after we’ve done it, and we change ourselves in the process of doing it.” – LA Paul

// 09.04.25

Unskilling

09.03.25 // Medicine

Deskilling and automation bias will be big problems with useful AI, but what do you call it when someone never has to develop skills in the first place?

Unskilling?

(Apparently, a at least one new paper describes it as “never-skilling”)

My son’s middle school has a detailed AI usage policy. It’s hard to believe medical training doesn’t require some thought on how to ensure robust, resilient skill acquisition.

Associate vs Partner Pay

08.25.25 // Radiology

A previous reader question:

What do you think is a fair compensation ratio for pre-partner to partner pay? It seems like a lot of jobs offer a 50 to 100 percent pay bump. Is there a threshold that should be a red flag?

I don’t think there is a red flag number.

These numbers mostly reflect supply and demand (and in some cases the impact of technical fees from center ownership after a buy-in).

Part of what will feel acceptable will depend on how long the track is. So if a group has a one-year track, you can tolerate a pretty big differential, but if they have a 5-year one, that might be unconscionable. If someone has a seven-year track, I probably wouldn’t want a big differential—that’s a long time to be paid less. (Given the number of unknowns over almost a decade, I  also think it would be very hard to know if you’re working toward a healthy return on that sweaty equity over such a long period).

Part of it will also depend on how high partner pay is. If a group has truly incredible contracts or an amazing real estate portfolio, it may make sense to accept a large temporary differential to enjoy potential massive returns on that time over the long term.

So I don’t think there’s a set number for it. I think it’s more a matter, unfortunately, of the holistic view.

The reality is that if you look at private practices over the past five years, everyone has shortened their track and bumped associate pay. I think most practices, especially in competitive areas, are largely doing what they can to balance recruiting desirability and providing perks to partnership.

Especially when hiring fresh graduates, it’s also not uncommon for a practice to lose money on its new hires for a while until they get up to speed. The reality is: the practice is often investing in you upfront. Partners also take risks that associates don’t, so there have to be some benefits to being a partner.

So again to summarize: it’s all supply and demand. These are businesses, and fairness is in the eye of the beholder. Years ago, when the job market was tight, we had long tracks and big differences. We are in a different era. Tracks and pay are what they have to be to recruit, and the better the offer relative to a partner, the more desperate the need to recruit or the more challenging the competition for recruitment is. The increasingly nationwide market for teleradiologists isn’t finished having its ripple effects.

So I am entirely unwilling to say there’s a rule of thumb here. Everything is local, but even then, sometimes things are good on paper because they have to be to be competitive in the market, which might mean they’re not competitive in some other way that’s harder to measure.

There are few shortcuts to evaluating jobs, few true red flags, and no ways to entirely de-risk the big decision of where to work.

Justified Leisure

08.21.25 // Reading

On the spurious need to justify leisure for leisure’s sake, via Four Thousand Weeks:

John Maynard Keynes saw the truth at the bottom of all this, which is that our fixation on what he called “purposiveness”—on using time well for future purposes, or on “personal productivity,” he might have said, had he been writing today—is ultimately motivated by the desire not to die. “The ‘purposive’ man,” Keynes wrote, “is always trying to secure a spurious and delusive immortality for his actions by pushing his interests in them forward into time. He does not love his cat, but his cat’s kittens; nor in truth the kittens, but only the kittens’ kittens, and so on forward forever to the end of cat-dom. For him, jam is not jam unless it is a case of jam tomorrow and never jam today. Thus by pushing his jam always forward into the future, he strives to secure for his act of boiling it an immortality.

This is, in part, an invocation to stop making everything count for something and just, you know, be. But, that’s hard:

It’s like trying too hard to fall asleep, and therefore failing. You resolve to stay completely present while, say, washing the dishes—perhaps because you saw that quotation from the bestselling Buddhist teacher Thich Nhat Hanh about finding absorption in the most mundane of activities—only to discover that you can’t, because you’re too busy self-consciously wondering whether you’re being present enough or not.

Soon, leisure isn’t very leisurely. It’s just a different kind of job:

The regrettable consequence of justifying leisure only in terms of its usefulness for other things is that it begins to feel vaguely like a chore—in other words, like work in the worst sense of that word. This was a pitfall the critic Walter Kerr noticed back in 1962, in his book The Decline of Pleasure: “We are all of us compelled,” Kerr wrote, “to read for profit, party for contacts … gamble for charity, go out in the evening for the greater glory of the municipality, and stay home for the weekend to rebuild the house.”

When was the last time you really did something without an eye toward some other goal?

In his book Sabbath as Resistance, the Christian theologian Walter Brueggemann describes the sabbath as an invitation to spend one day per week “in the awareness and practice of the claim that we are situated on the receiving end of the gifts of God.” One need not be a religious believer to feel some of the deep relief in that idea of being “on the receiving end”—in the possibility that today, at least, there might be nothing more you need to do in order to justify your existence.

and

“Nothing is more alien to the present age than idleness,” writes the philosopher John Gray. He adds: “How can there be play in a time when nothing has meaning unless it leads to something else?”

and

Taking a walk in the countryside, like listening to a favorite song or meeting friends for an evening of conversation, is thus a good example of what the philosopher Kieran Setiya calls an “atelic activity,” meaning that its value isn’t derived from its telos, or ultimate aim.

You can stop doing these things, and you eventually will, but you cannot complete them.

You cannot complete them.

Cosmic insignificance therapy is an invitation to face the truth about your irrelevance in the grand scheme of things. To embrace it, to whatever extent you can. (Isn’t it hilarious, in hindsight, that you ever imagined things might be otherwise?) Truly doing justice to the astonishing gift of a few thousand weeks isn’t a matter of resolving to “do something remarkable” with them. In fact, it entails precisely the opposite: refusing to hold them to an abstract and overdemanding standard of remarkableness, against which they can only ever be found wanting, and taking them instead on their own terms, dropping back down from godlike fantasies of cosmic significance into the experience of life as it concretely, finitely—and often enough, marvelously—really is.

Read some more thoughts and quotes from Burkeman’s excellent book in Productivity is a Trap, Inescapable Finitude, and Choosing Rocks.