Ben White

For the Patients

01.28.24 // Medicine

There’s a Derek Sivers quote about business in Anything You Want that I think applies well to healthcare. I’ve replaced “customer” with patient”:

Never forget that absolutely everything you do is for your patients. Make every decision — even decisions about whether to expand the business, raise money, or promote someone — according to what’s best for your patients.

One key here is that you can’t just consider what only best for your patients right now, but also what will be best for your patients in the long run. We can ask that question as individual doctors, as groups/practices/hospitals, as specialties like radiology, and as healthcare professionals as a whole.

You, your business, and your industry need to be healthy and strong enough to keep providing the best possible care into the indefinite future.

We can’t prioritize short-term thinking through dashboards, growth, and other easy measurables over second-order thinking.

Radiology Partners and a “Comprehensive Set of Financing Transactions”

01.25.24 // Radiology

Last week, Radiology Partners released an announcement that it was “commencing a comprehensive set of financing transactions to strengthen its financial position.”

Setting the Stage

Going into 2024, RP was already cashflow negative (i.e. losing money) to say nothing of the massive debt payments due this year and next. For a reminder of what was coming, recall this slide:

But it’s more than that: In addition to having no ability to pay these loans back, RP told lenders they’re a month or two away from running out of money period. They’ve been trying to raise equity (i.e. sell a stake in the company) to pay off some of the debt including a big effort last summer, but even their own materials assume the need to refinance. (No big surprise there, it’s common practice in this highly-leverage industry.)

However, there’s a chicken and egg problem. Recall that in a bankruptcy, debtholders get paid before equity holders get a dime. No one wants to put fresh money into a failing business about to go bankrupt, so no one in their right mind would invest if the current debtholders weren’t willing to “amend and extend.” But debtholders aren’t going to A&E unless they think their odds of getting money back are improved by pushing back the due date. They want to see a really healthy business or at least fresh capital coming in to keep things afloat.

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United is Still Fighting Radiology Partners

01.22.24 // Radiology

As you might recall, UnitedHealthcare sued Radiology Partners in April 2023 for an alleged pass-through billing scheme during an ongoing arbitration process about underpayment initiated by RP’s subsidiary group Singleton Associates in April 2022. RP called shenanigans. The judge made them fold that complaint into the ongoing arbitration process, in which there are currently three phases:

  • Phase I: Determine which contract is active and should be used to determine charges: the original very lucrative 1998 one vs the 2020 one United started using (basically unilaterally)
  • Phase II: If applicable, determine damages from Phase I
  • Phase III: Evaluate the billing fraud accusation, which will be treated as a separate question from Phase I.

Last fall, RP won an interim award from the initial phase of that process to the tune of $153 million. United’s statement at the time: “We do not agree that Singleton will recover an award from UnitedHealthcare.”

In October, RP then quicky filed an application hoping to treat the “interim” award as a “final” award and get that money ASAP. United filed their own application to “vacate” that “interim arbitration award” (if you’re curious, the actual filing is linked from that page).

Their stated reason? Among other things, the arbitration panel might be vacating its own award itself. Err…what?

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Radiology Ergonomics and Productivity

01.18.24 // Radiology

I’ve recently added a couple more short entries on top of my initial 4-post series on radiology setups/hardware, ergonomics, and productivity.

For convenience, here are the articles:

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1. The Best Radiology Setup/Workstation Equipment

Here’s what I have idiosyncratically landed on as a stable happy set-up that balances efficiency and comfort (and an editorial selection of those favored by others).

Life is too short to use what comes with your computer.

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2. How I Use the Contour Shuttle for Radiology

This post could have been titled: Why and How to Use an Offhand Device for Radiology, Or maybe even: How to Make the Most of All Those Extra Buttons on Your Gaming Mouse or Similar Device

More buttons! Better scrolling! Save your wrist! Feel like a PACS ninja!

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3. AutoHotkey for Radiology

AutoHotkey is powerful free software you can use to control your computer and generate simple (or complex) macros to automate tedious or repetitive tasks.

Achieve frictionless hands-free dictation (and more!)

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4. Making the Most of PowerScribe

PowerScribe is ubiquitous in radiology practices across the country, and it’s the only dictation software I use in my job. It has many flaws, but there are plenty of things we can do to make the most of it…Here are some tips for making PowerScribe (360) suck less.

Don’t be a passive victim of bad corporate software.

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5. Radiology Toys (TL;DR)

For the use-with-your-hands part, here are some quick contexts and a single choice for each that you can implement wherever you work:

Quick highlights: Optimizing is a worthy investment of time/energy/money.

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6. Using the Zelotes C18 for Radiology

The Zelotes is the cheapest vertical mouse that doesn’t suck, and it has enough buttons that it’s useful for everyday PACS functionality no matter where you work.

How to think about mice for radiology with a special focus on a very inexpensive “vertical mouse” (along with some alternatives).

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Feel free to bookmark this post, because I’ll also add any follow-ups here.

Management by Values

01.16.24 // Miscellany

Steve Jobs, as collected in Make Something Great:

There’s a lot of management techniques. I’m sure you study a lot of management techniques. When I was younger, it was management by objective. It’s all a crock. They’re all after-the-fact management techniques: “You’ve failed, and I know that because we are going out of business tomorrow.” All after the fact. “You’ve ruined this department; all the good people have left. So now I’m firing you.” “You’ve accomplished none of your objectives.” It doesn’t work.

And a really smart guy I met a long time ago who used to teach at Disney University—Walt Disney recruited him to run Disney University, actually—he told me about his point of view, which I’ve remembered to this day. He called it management by values. What that means is you find people that want the same things you want, and then just get the hell out of their way.

The way I describe it is, let’s say we’re all going to take a trip together. The first thing is to figure out where we all want to go. The worst thing is if we all decide we want to go to different places. You can never manage it. [Pointing] You want to go to New Orleans. You want to go somewhere else. I want to go to San Francisco. You want to go to San Diego.

It doesn’t work. Right?

But if we all want to go to San Diego, that’s the key. Then we can argue about how to get there. [Pointing] You think it’s better to walk. You think it’s better to take a plane. You think it’s better to take a train. We’ll figure that [part] out. Because if I say, “I want to take a train to San Diego,” and somebody goes, “That’s really stupid! It will take three days! We can fly and be there in an hour,” I’ll go, “Oh. OK.” Because, actually, I want to go to San Diego. So if I can get there in an hour [flying], I’ll ditch my idea about the train.

That’s what management by values is. It’s finding people with passion that want to go to San Diego—who want to go to the same place you want to go to! Right? That’s the key.

When I think about culture as it pertains to medicine, and how large institutions falter, academic departments implode, and even smaller groups struggle, I think so much of it boils down to this:

There is no management technique to consistently make a group of people want to go to the same place after the fact.

Many management techniques and leadership styles can spoil a great enterprise, but perhaps none can craft one from an unformed mass of individuals, especially not the model of the business suit directing an army of practitioners.

C.S. Lewis (of Narnia fame) on peer learning:

It often happens that two schoolboys can solve difficulties in their work for one another better than the master can. The fellow-pupil can help more than the master because he knows less. The difficulty we want him to explain is one he has recently met. The expert met it so long ago he has forgotten.

I’ve always been a big proponent of peer teaching and peer mentoring in medicine. I also often wonder if I’m getting worse at teaching the basics as I get older.

// 01.15.24

Prenuvo: The Turtle Catcher

01.12.24 // Medicine, Radiology

Excellent piece on Prenuvo’s whole body scans by Dr. Dhruv Khullar in The New Yorker:

Doctors sometimes use a barnyard analogy to talk about the vast differences between cancers. A tumor can be a turtle, a bird, or a rabbit, depending on its speed and ability to escape; the goal of screening and treatment is to fence the cancer in. Turtles move so slowly that, fence or no, they’ll never make it out. Birds are so flighty that fences are irrelevant; even if you spot them, there’s no real way to stop them. Only the rabbits can actually be fenced in. By some estimates, at least a quarter of cancer diagnoses can be considered overdiagnoses. These tumors are turtles; they never would have left the barn.

South Korea inadvertently illustrated this point when a government program, starting in 1999, offered free screenings for several common cancers. A thyroid-cancer screening wasn’t included, but many patients opted to add one for a fee. Between the early nineties and the early twenty-tens, rates of thyroid cancer soared fifteenfold—a development that would have been worrying, except that death rates from thyroid cancer never rose, and remained very rare. Diagnosing these cancers wasn’t saving lives: almost all were papillary thyroid tumors, which are present in as many as a third of all adults and rarely cause problems. Nonetheless, tens of thousands of South Koreans had their thyroids removed and started taking lifelong hormone supplements. They’d fenced in turtles.

Excellent, accessible illustration of what screening is for and why more isn’t always better. There will always be happy individual narratives of people saved by screening even when, on the whole, a particular screening test is net harmful. Judging a population tool that results in society-wide costs based on individual unaggregated results is a fool’s game.

Quoting a scene from Scrubs, the most accurate medical television show of all time:

In a 2004 episode of the sitcom “Scrubs,” Bob Kelso, the chief of medicine at Sacred Heart Hospital, runs into a fellow-doctor, Perry Cox, in the hallway. “I am considering offering full-body scans here at Sacred Heart,” Kelso says. “What do you think?”

Cox looks appalled. “I think showing perfectly healthy people every harmless imperfection in their body, just to scare them into taking invasive and often pointless tests, is an unholy sin,” he says.

“Does sound a little sketchy ethically, doesn’t it?” Kelso says. “Thanks, Perry.”

It’s feasible there could be a future world where very frequent low-cost whole-body screening is helpful, particularly if the follow-up for turtles was nearly always just more low-cost whole-body screening and not something costly and/or invasive. But today, in our current strained inefficient system with its high costs–and its current players and their financial motives–this is unlikely to be the case.

2023 Word of the Year

01.10.24 // Miscellany

The American Dialect Society chose their 2023 word of the year: enshittification.

From its coiner, Cory Doctorow:

Here is how platforms die: first, they are good to their users; then they abuse their users to make things better for their business customers; finally, they abuse those business customers to claw back all the value for themselves. Then, they die. I call this enshittification.

Think every social social media company, Google, Amazon, etc.

I first discovered Cory Doctorow eons ago via his unique science fiction novel set in Disneyland, Down and Out in the Magic Kingdom (which he somewhat famously simultaneously traditionally published commercially and also released for free in 2003 under a Creative Commons license, and which has been available for free ever since).

In unrelated news, Doctorow had a nice linkpost and summary of private equity and hospices last year.

Using the Zelotes C18 for Radiology

01.09.24 // Radiology

The Zelotes C18 (aka TRELC Gaming Mouse with 5D Rocker aka ZLOT Vertical Mouse) is a solid very inexpensive productivity and ergonomics upgrade. If you’ve never used a mouse other than whatever’s plugged into the computer already, this currently sells for just $29.

It’s probably the best way to trial a vertical mouse for radiology without breaking the bank. A vertical mouse is like a regular mouse titled slightly on its side. It removes the pronation at the wrist by mimicking a “handshake” position, and many people (myself included) have found it helps with chronic wrist strain. That said, there’s zero data backing up those purported ergonomic benefits, and obviously vertical mice remain very niche. It’s intuitive that the form factor could help, and I think it does help (me), but I think even more strongly that there are probably idiosyncratic and personal preference factors (and placebo?) at play. There’s also a bit of a learning curve, so you need to stick with it for at least a couple of weeks.

The Zelotes is the cheapest vertical mouse that doesn’t suck, and it has enough buttons that it’s useful for everyday PACS functionality no matter where you work. Thanks to on-board memory–after initial setup/configuration at home–it will work on any other computer you plug it into without any software/drivers being installed. While the Logitech MX vertical feels slightly better in the hand, the Zelotes is better suited for most PACS due to its button configuration. It’s also a little smaller, which will help for those with smaller hands (a classic MX complaint is that’s a bit large for smaller hands).

Do I wish it had a few more buttons? Sure. But the 4-way joystick is perfect for window/level presets, and the additional two side buttons, joystick push click (hence “5D” rocker), mouse wheel click, and the extra top button give you several more presets to play with. How you map those buttons will obviously depend on your preferences, your PACS itself, and whether you want to use the mouse for dictation controls or just PACS shortcuts.

Here’s mine for the hospital, where we currently (but not for long!) use GE Centricity:

Recall that I use an off-hand device for the additional important controls (previous/next field, measuring tools, delete, etc) and AutoHotkey to control dictation without a dictaphone.

If you don’t want a rainbow glowing mouse (too much fun for me), the LED can be turned off easily in the settings.

The mouse can house two profiles in its memory at a time. You can save one button on the mouse to toggle between profiles if you need/want to switch between them on the fly. Alternatively, I personally find myself working with different PACS systems on different days, so I fully utilize every button on the mouse and then switch between the two stored profiles in the configuration software on my home computer. It only takes a second.

A Few More Expensive Conventional Alternatives

Gaming:

If you’re not interested in the slightly weird form factor but do want a solid mouse with a great but not overwhelming number of extra buttons for PACS control, try the G604 Lightspeed. It also has on-board memory so that it will work on any workstation after initial setup.

Pretty Cheap with Infinite Buttons:

If you want an inexpensive mouse with a 12-button thumb grid and on-board memory, try the UtechSmart VenusPro. To go totally nuts, you can map the accessory index finger button to a modifier key like ctrl or shift and add a whole layer of additional commands (though how you’ll memorize them and embed them in muscle memory is a serious question).

Conventional:

For a daily driver regular/non-gaming mouse, I think the Logitech MX Master 3 remains the best. It has amazing build quality with a best-in-class scroll wheel and feel for a conventional mouse. With the Logitech Options software installed, you can set up mouse button functions on a per-application basis.

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More mouse and workstation considerations are here.