$50 to join another physician survey panel (All Global Circle)

All Global Circle has expanded its physician survey program and is now paying the biggest sign-up bonus around: $25 for signing up and another $25 for validating your account. If you don’t get a survey in the first 90 days and stay active by logging in twice a month, you’ll also receive an additional $25 “loyalty” bonus.

Signing up for these offerings is also an easy way to support me/this site (so thank you!)

Bedside Business (Podcast)

I did a Q&A about student loans and the transition to residency (as well as a dash of passion is overrated and medical education is toxic) with the fine students across the DFW Metroplex at TCOM this spring, and it’s now available as an episode of the Bedside Business Podcast (Apple | Spotify | Google | Stitcher).

The Zoom recording audio is a smidge choppy at times but not enough to hurt as long as you slow down to 1.5x to account for my speed!

Driving at Stable

A classic Jeff Bezos quotation:

I very frequently get the question: “What’s going to change in the next 10 years?” That’s a very interesting question.

I almost never get the question: “What’s not going to change in the next 10 years?” And I submit to you that that second question is actually the more important of the two.

You can build a business strategy around the things that are stable in time. In our retail business, we know that customers want low prices, and I know that’s going to be true 10 years from now. They want fast delivery; they want vast selection. It’s impossible to imagine a future 10 years from now where a customer comes up and says, “Jeff I love Amazon, I just wish the prices were a little higher.” Or, “I love Amazon, I just wish you’d deliver a little slower.” Impossible.

So we know the energy we put into these things today will still be paying off dividends for our customers 10 years from now. When you have something that you know is true, even over the long term, you can afford to put a lot of energy into it.”

I recently attended a “leadership” seminar about (radiology) healthcare ecosystems and change. As with all virtual events since early 2020, discussion of the Covid-19 pandemic played an outsized role, and the nature of complexity and change were much pontificated about.

But no one over the course of two days–no one–mentioned the stability of the core mission. The strategic analyses–such as explicit or implicit utilization of SWOT–were happy to focus on anticipation and interception of perceived changes and threats, but no one spared a breath for what they thought wouldn’t change. We talked about trends in corporatization and productivity metrics, group consolidation, encroachment by midlevels and other specialties, downward reimbursement pressure, the push for 24/7 subspecialty staff coverage, lifestyle and burnout, and AI and data science.

To be sure, these and all other big changes are important, but you also can’t lose sight of the underlying purpose of the business in all the pivoting.

What can we say about medicine that is not going to change in 10 years? What is our stability north star?

(Yes this is a rhetorical question cop-out.)


The Availability Heuristic in Practice

We all use mental models (heuristics, rules of thumb) across a host of simple and complex problems. They often work; they sometimes don’t. You shouldn’t (and can’t) avoid having and using them, but you should be aware of them (and their limitations).

The Influence of the Availability Heuristic on Physicians in the Emergency Department” is a cute little paper demonstrating recency bias in real-life practice:

Heuristics, or rules of thumb, are hypothesized to influence the care physicians deliver. One such heuristic is the availability heuristic, under which assessments of an event’s likelihood are affected by how easily the event comes to mind. We examined whether the availability heuristic influences physician testing in a common, high-risk clinical scenario: assessing patients with shortness of breath for the risk of pulmonary embolism.

The sample included 7,370 emergency physicians who had 416,720 patient visits for shortness of breath. The mean rate of pulmonary embolism testing was 9.0%. For physicians who had a recent patient visit with a pulmonary embolism diagnosis, their rate of pulmonary embolism testing for subsequent patients increased by 1.4 percentage points (95% confidence interval 0.42 to 2.34) in the 10 days after, which is approximately 15% relative to the mean rate of pulmonary embolism testing. We failed to find statistically significant changes in rates of pulmonary embolism testing in the subsequent 50 days following these first 10 days.

Of course, one of the biggest components of the availability heuristic in real life isn’t just how recent the event is (though that’s what’s measurable in this sort of dataset). It’s anything that makes certain events easier to recall. This is, for example, why some of our mistakes or surprise diagnoses can have an outside impact on our practice. We remember that unexpected PE we didn’t see coming more than the many more common examples of the negative CTA.

(Further reading availability bias: Farnam Street.)

The Jargon of the Business Dark Arts

From Brian Alexander’s The Hospital: Life, Death, and Dollars in a Small American Town:

(Phil Ennen, one of the main characters, is the CEO of a struggling small-town community hospital in Bryan, Ohio.)

That was the world where Ennen and the vice presidents now found themselves as they listened to consultants they were auditioning to help create a strategic plan. “Transformational changes dictate that leaders within the physician enterprise focus on enterprise sustainability.” So they drove. They drove at “solutions.” The consultants offered entire suites of solutions. The solutions could be “leveraged” toward “accelerating the journey to risk capability.” There’d be “applied analytics” in “the Achieve solution set,” which was “purposely designed to assist physician enterprise leaders to align compensation models and strategic priorities, maximize productivity.” “The Achieve solution set not only drives current performance improvement but also establishes the forward-looking strategic, financial and operational structures to provide for the future risk capable physician enterprise.” Change was driven. Results were driven. Everything was “forward-looking” and “dynamic.” Zoom!

It wasn’t just about style. Ennen thought the world—and especially the world of medical care—was complicated enough without further obscuring meaning and understanding by spouting terms of the business dark arts. Such terms were deliberate obfuscations, thrown up as fortress walls to keep the uninitiated outside and throwing cash over the walls to the mysterious magicians inside so they’d shout down their wisdom. Now, though, like it or not (and he didn’t), Ennen and the others were knocking on the gates of the consultants.

What a great line by Alexander: “Such terms were deliberate obfuscations, thrown up as fortress walls to keep the uninitiated outside and throwing cash over the walls to the mysterious magicians inside so they’d shout down their wisdom.”

The book came out in March of this year and is a meticulous deep dive and narrative take of modern American healthcare through the lens of small-town America as a community hospital struggles to stay independent and survive.