Years ago, when I was a resident and the ABR Core Exam was still novel, the ABR offered a lengthy “ABR CORE Examination Study Guide” PDF, which—in addition to over a hundred pages of endless bullet points listing every conceivable topic in radiology—included 57 official practice questions at the end (with an answer key).

They took that down years ago. But, thanks to the miracle that is The Internet Archive, you can still enjoy a copy of that PDF here. Well worth doing in the final weeks leading up to the June exam. Enjoy!

(Other nonofficial question resources are discussed here.)

((Lest there be any confusion, I have no working relationship with the ABR. In fact, I’m probably a persona non grata. These are just questions that they once posted on a public-facing website.))

It should go without saying, but I’ll say it anyway: these are my opinions, formed from the combination of my biases, my experience as a radiologist since beginning residency 10 years ago, and my many conversations with radiologists across the country. You don’t have to agree with me.

Not Enough and No Help Coming

For today’s needs and today’s technology, we have simply produced far too few radiologists. There is a sizable and worsening radiologist shortage, and there is no end in sight on the basis of increased radiologist supply. There are currently 1788 separate job postings on the ACR job board. Imaging volumes are increasing between 3 to 5% per year (increasingly including low-yield complex exams), but no one is seriously attempting to address utilization at any level. Nationwide, the supply of radiologists is basically flat. The anticipated wave of retirements from vested PE buyouts is just beginning.

It’s true that reimbursement has been steadily falling and that radiologists have been forced to read more in order to maintain their income, but it seems that even there, any excess workforce tolerance for higher workloads has been saturated. If anything, the tighter job market after the 2008 crash and the desire to maintain income against that downward reimbursement pressure masked the problem. Burnout is now so rampant and commonly discussed that it’s mostly just meme bait on social media.

Turnaround times are worsening. For example, a memo to the medical staff of Ascension Saint Mary in Chicago was making the rounds back in March:

Our current Radiologist group, RadPartners, has been experiencing challenges with physician coverage for some time. As a result of this radiologist shortage, outpatient exams are taking anywhere from one to six weeks to be read.

Six weeks?! I don’t think most practices have much more to give before flaming out, and many groups are shedding contracts in an attempt to right-size their workloads. (This was in fact a contract in its final months that RP had already terminated. [Also note, given comments I’ve received: this quotation was included for flavor, not because RP or this one group is the basis for this article’s argument.])

There’s a generational shift contributing as well. People’s understandable desire to have a better lifestyle also means that in some cases we require more young radiologists to cover the jobs of those leaving the workforce. It wasn’t that long ago that most radiologists covered their own nights on a rotation (or paid for tele coverage) and no one had dedicated night teams. Then it was normal to see a 7-on/7-off schedule. Now 7/14 and even 7/21 schedules are increasingly common. When you need three people to do the job of one person, that isn’t going to help with the workforce shortage.

Frankly, I think there’s no chance of radiologists meeting demand without a paradigm shift of some kind, either the long-awaited mass efficiency gains from meaningfully helpful AI products (maybe good?) or the significant expansion of the role of midlevel providers in image interpretation (highly suboptimal and currently not permitted). It’s hard to imagine a world where volumes actually go down in this country, but that would also work.

The training pipeline is essentially fixed in size and long in duration. Even opening up more training spots would take years to help. If the shortage gets worse, then turnaround times will continue to lengthen (and patients suffer) and hospitals will struggle to get coverage (and patients suffer). That will be the time when the government/Medicare/national organizations start advocating against the currently protected role that radiologists hold for imaging interpretation.

Years from now, there may be a world where there are too many radiologists, but that world is one where radiologists are performing a substantially different role than they are today, and I’m not sure there’s any way to meaningfully prepare for that possible future while also solving the problem of getting today’s work done. (more…)

From an opinion piece in AJR recently titled “The Case for Presence as a Source of Professional, Educational, and Social Fulfillment“:

Although the long-term impact on social wellbeing of working virtually compared to working in-person is not yet fully understood, physical presence is likely to be conducive to establishing connectedness.

This is a valid knock on teleradiology. Working alone by yourself just isn’t the same as having real colleagues, hanging out with peers, and enjoying spontaneous interactions throughout your work day. I absolutely agree. Sure, having some remote work is great. It’s flexible and efficient. But I took the specific job in private practice I did precisely because I wanted to have peers, teach residents, and otherwise have a varied work-life experience (yes, including working from home sometimes).

All things being equal, we really benefit from spending time with real, live humans. The data show that having a “best friend at work” is a powerful force.

But.

The problem with this kind of article is that it’s a reflection of the academic bubble. When we draw a comparison between a typical academic center or hospital-based practice and teleradiology, we miss the fact that many, many radiology jobs are not team-based daily work. Yes, there are still jobs where you’ll drive to the hospital and work with your peers. There are even some with communal reading rooms and the chance to socialize. But the reality of modern private practice is that a lot of radiologists drive around town to sit by themselves in small reading rooms in the back of outpatient imaging centers located in strip malls.

The false dichotomy (tele = inescapable loneliness, non-tele = Shangri-La) misses the fact that the so-called downside of a remote/at-home practice applies equally well to the reality of private practice in many locales. If you’re commuting just to cover contrast from a dark closet somewhere, you’re not really benefiting from the perks of presence.

The key to meaningful comparison always rests on a foundation of fairness (apples to apples, not apples to oranges). Considering the enrichment you might get from physical presence in an academic medical center radiology position is one important consideration, but it’s ultimately a poor reference when comparing the jobs that many residents in many markets will decide between.

The more salient distinction between a teleradiology position and a local private practice job is the difference between sitting in your pajamas at home versus providing contrast coverage and the occasional procedure at an outpatient imaging center. Realistically, for better or worse, plenty of recent graduates don’t like doing procedures and don’t socialize with the techs. With that reality, it’s not hard to see why even trainees are interested in jumping straight into teleradiology. They’ve never experienced the relative isolation of being the only radiologist at a facility, let alone the isolation of being entirely remote.

Radiologists can argue themselves red in the face about how important it is to be visible and available to clinicians in order to demonstrate our value and the importance of face-to-face communication. That’s all well and good. But it is also outside the locus of control for an individual radiologist pursuing an individual job. The majority of imaging volume is outpatient imaging, and the majority of communication we do is over the phone. The volume is there, and the positions exist. How can we blame radiologists for taking the jobs that are available? The market consolidation from the growth of massive academic medical centers and nationwide private equity conglomerates coupled with a worsening radiologist shortage has fundamentally changed the workforce.

The reality when assessing an individual position is that there are good and bad types of every job. There are assuredly some teleradiology positions that have good support with built-in ways to reach out to colleagues for second opinions and reasonable productivity demands. And there are jobs that are local and in-person but spread out enough with bad IT infrastructure that you may feel even more alone.

You have to know what it is you want, and you have to evaluate each job on its own merits. You have to ask questions.

Yes, we’d probably all be happier feeling like we were part of something. I like my remote work days, but I have no interest in an exclusively teleradiology position. I agree with the thrust of the paper: presence matters. Unfortunately, most conventional jobs simply don’t offer that much presence and many that do are so busy that you can’t enjoy it.

So, ultimately, the distinction isn’t really just teleradiology versus in-person. It’s community vs isolation.

From “Automation Bias in Mammography: The Impact of Artificial Intelligence BI-RADS Suggestions on Reader Performance“:

Inexperienced radiologists were significantly more likely to follow the suggestions of the purported AI when it incorrectly suggested a higher BI-RADS category than the actual ground truth compared with both moderately (mean degree of bias, 4.0 ± 1.8 vs 2.4 ± 1.5; P = .044; r = 0.46) and very (mean degree of bias, 4.0 ± 1.8 vs 1.2 ± 0.8; P = .009; r = 0.65) experienced readers.

Small but pretty clever study.

“Automation bias” is an insidious combination of anchoring and the authority fallacy, and it demonstrated a huge (though experience-mediated) effect here. We are still very much in the early days here (most radiologists are still very skeptical about the current powers of “AI” tools).

As machine learning tools grow in power and complexity, they will undoubtedly become a larger part of the radiology workflow. But counter to enabling inexperienced practitioners to function without oversight (e.g. a non-trained non-radiologist working independently with AI bypassing radiologists), we will instead need more robust skills: Raising the floor to miss fewer fractures and PEs is the easy part; it takes knowledge and experience to countermand the computer you increasingly rely on.

This isn’t going to be easy.

Earlier this year at the Texas Radiological Society annual meeting, I attended an ABR update given by current ABR president, Bob Barr, where he announced the rapid progress of the ABR’s plan to revitalize the Certifying Exam to address widespread discontent. I wrote about it here. The plan was to announce the change no later than June but potentially as early as April. The takeaway summary at the end of that short post?

But the ABR did reiterate that their hope for the Certifying Exam is a better demonstration of the skills needed for general practice.

But no, I don’t think they’ll be bringing back the oral boards.

The news broke on April 13.

I was wrong.
(more…)

Update 10/24/2023: The case went to arbitration this fall, and the panel has initially ruled in favor of RP. United is going to fight this, and there are still outstanding counterclaims from United against RP. From the Radiology Business article: “We do not agree that Singleton will recover an award from UnitedHealthcare,” the Minnetonka, Minnesota, company said.

* * *

The big radiology news of the week? United Healthcare—generally felt to be a font of diabolical greed—is suing Radiology Partners:

In its unscrupulous pursuit of profits Radiology Partners orchestrated a pass-through billing scheme intended to defraud United, its customers, and its members of tens of millions of dollars.

Takes one to know one, as the childhood saying goes. You can read the initial complaint here.

United claims that RP illegally funneled the work of multiple groups across and even outside Texas through its most lucrative contract held by a small group in Houston (so-called ‘pass-through’ billing fraud).

The suit alleges that Singleton, a small group in Houston that RP bought in 2014, had an especially lucrative contract dating back to 1998 for ~6x Medicare rates “to practice at two local hospitals.” According to the story, everything was going just fine, until…

That changed in 2014 when Singleton was effectively acquired by Radiology Partners. Once Singleton was controlled by Radiology Partners, Radiology Partners caused Singleton to breach the Agreement by submitting claims for services performed by providers who were not shareholders, partners, or employees of Singleton (the “Unauthorized Providers”) and who were not performing services at hospitals where Singleton was contracted. Likewise, Radiology Partners caused Singleton to fraudulently bill United for services performed on individuals who were not Singleton’s patients.

Now, groups merge all the time or sell to hospitals to take advantage of stronger contracts, so that’s clearly not an issue in all circumstances. It depends on whether or not RP is truly engaged in true pass-through billing or not:

Pass-through billing occurs when an ordering physician requests a service and bills insurance for it but does not perform the service, nor does anyone under the physician’s direct employ. Insurance companies generally forbid this practice.

Per United, the Singleton contract specifically “prohibited Singleton from assigning its rights and responsibilities under the contract without written consent from United, and required Singleton to notify United of any changes in ownership or control.”

As in, RP wasn’t actually allowed to buy them in order to funnel every Texas claim through that Tax ID.

This was presumably RP’s exact business model.

In 2013, the Singleton agreement had 70 unique providers. By 2022, there were more than 1000 providers billing under the Singleton contract. For more context, according to RP’s recent 10-year anniversary press release, RP employed ~3300 radiologists in 2022. (So…1/3 of RPs nationwide practice was added to this contract? Yikes?)

There are also some nice digs about RadPartners as a company in section “III. RADIOLOGY PARTNERS’ BLIND PURSUIT OF PROFIT” (yes, again, United Healthcare clearly has a pathological sense of irony):

While claiming that medical groups are “Locally Led,” Radiology Partners carries out its operations through a web of subsidiaries and affiliates under the umbrella “RadPartners.”

In some cases, medical groups are organized as professional associations. When Radiology Partners takes over, these professional associations become owned by physicians who are executives at Radiology Partners, thus giving Radiology Partners effective control over the medical group.

Radiology Partners controls various functions of these professional associations, including payor contracting and billing.

In exchange for these services, Radiology Partners siphons off large amounts of revenue from the medical groups. Indeed, on information and belief, the affiliated medical groups no longer retain any profits resulting from the radiology services that they provide, and all profits are instead kept by Radiology Partners.

Ouch. Back to the lawsuit, so how does RP get away with keeping the old contract when there is a new owner?

On October 31, 2014, Singleton filed an Amended and Restated Certificate of Formation that changed Singleton’s ownership and made Anthony Gabriel the only member, officer, or director of Singleton. In addition to becoming the sole member, Gabriel became the sole officer and director of Singleton.

Anthony Gabriel is a co-founder of Radiology Partners and its Chief Operating Officer.

No notice was ever provided to United of any change in Singleton’s ownership.

By appointing Gabriel as the sole member and director of Singleton, Radiology Partners can exercise control over all actions taken by Singleton without formally owning it. Radiology Partners and Singleton structured their relationship to remain two separate entities.

And that, I suspect, is the crux. In the real world that you or I live in, RP owns this practice. But they own it by siphoning off all the profits and by installing one of their own as the sole officer with all operational control. But, Singleton remains Singleton. While it’s not exactly “locally led” if Dr. Gabriel is the sole director, Singleton remains a separate legal entity.

The dicier part of the story is that obviously all of these extra rads clearly don’t really work for or at Singleton. I’m not sure what justification RP uses here if that is specifically stated in the contract. It seems like an eating-your-cake-too situation where RP wants to take advantage of a lucrative contract by not formally owning a local practice but also wants to pretend that nonaffiliated RP practices are somehow all the same. After all, Singleton isn’t the one that bought these other “locally led” groups.

While the Agreement contemplated that providers could be added to the Singleton medical group subject to the other terms of those [sic] Agreement, only providers who were actually working for Singleton—and providing services to Singleton patients—could be added to and have their services billed under that contract.

United has since learned that the vast majority of providers that Singleton, acting in concert with Radiology Partners, added to the Agreement were Unauthorized Providers. They were not employees, shareholders, or partners of Singleton and were not providing services to Singleton’s patients (i.e., at hospitals where Singleton was previously contracted to provide radiology services).

I’m obviously not a lawyer, but it would seem the precise wording in the contract for this claim is basically everything. Twitter is full of eating popcorn gifs at the moment.

* * *

The initial complaint of a lawsuit is by definition a one-sided narrative. And, one assumes, this is the strongest story United can tell. Obviously, this has been going on for years, and it’s completely unclear why this is happening now. My initial reaction was to assume that RP and United were in a heated billing dispute of some kind and this was United playing hardball.

RP, for their part, is indeed arguing just that, saying this is just a cynical maneuver in an ongoing reimbursement fight:

We believe UHC’s complaint represents an obvious attempt to delay or disrupt the conclusion of an underpayment dispute currently in arbitration involving a Texas-based RP-affiliated practice.

The lawsuit as a bullying tactic remains alive and well.

It’s challenging to know who is right and wrong this early in the plot. It doesn’t help that neither company is deserving of anyone’s sympathy. I suspect for most observers it’s like hoping for a rare double knockout: it’s a shame there can only be one loser.

As a layperson who reads the news, I am frankly not convinced the legal system even really works. For another radiology example, I enjoyed the legal briefs from the antitrust lawsuit against the American Board of Radiology, but even though I wasn’t impressed by the ABR’s lawyers or their various arguments, they still managed to get that suit dismissed. Clearly what I think doesn’t matter.

But, I will admit, this looks a little…er, fraudy? Perhaps this should come as no surprise given that the RP brass came from DaVita, itself no stranger to fraud (and which has paid ~$1 billion in settlements so far).

If this is just a 3D Chess negotiation ploy, the real question is: Will it work? And, will this get far enough that discovery leads to interesting revelations? From an outsider‘s perspective, it would seem likely that they will settle this quietly out of court for an undisclosed sum without admitting wrongdoing.

* * *

Other than the making public of a previously private spat between United and RP, what does this mean?

Well, for one, this is just one insurer in one (admittedly large) state. You know everyone is going to be pouring over their books looking for evidence of the same and watching closely to see how this turns out. This could be a big nothingburger or the harbinger of doom.

As for RP, how else does this affect things other than the obvious dollars at risk?

I won’t pretend to know how strong their case is, but again, if you read the complaint, it literally looks bad. As in, the raw optics aren’t great.

Now obviously I don’t have the mind of a large institutional investor. A lot of these PE roll-ups looked suspect to me even in the age of zero percent interest rates, and the history of the industry’s company management is mixed, to say the least. But If you’re running a fund considering buying RP’s distressed corporate debt or someone big enough to consider buying the whole thing, I don’t see why you would with this on the table. Yes, their massive leverage in the form of high-interest floating debt is a bigger problem. Yes, their revenue growth is already constrained by the current reimbursement climate and the tight job market. One insurer asking for millions isn’t necessarily a big deal when you already owe billions, but in the face of all these big-picture headwinds, I don’t think this is going to help their marketing department. RP needs help to deal with its debt, and unless they win very quickly, this lawsuit won’t help.

Lastly, I feel bad for some of the individual radiologists named in the suit. RP Executives aside, I doubt any of them knew how billing was being carried out on their behalf. I even recognize some names that no longer work for RP. Perhaps I am being unfair, but this is just one more strike against going to work for an RP company, especially for new graduates. Who wants to have their name dragged as part of a False Claims Act investigation, whistleblower complaint, or other lawsuit? This doesn’t need to be the future of our profession.