The Truth about Private Equity and Radiology with Dr. Kurt Schoppe

Have you ever talked to someone above you on the food chain—usually with the word manager, director, or Vice President somewhere in their job title—and after they depart, you just stared blankly into the distance while slowly shaking your head thinking, Wow, they really don’t get it. What a useless bag of skin?

Well, that’s the opposite of my friend Dr. Kurt Schoppe, a radiologist on the board of directors at (my friendly local competitor) Radiology Associates of North Texas and payment policy guru for the American College of Radiology where he works on that fun zero-sum game of CMS reimbursement as part of the RUC. He’s whip-smart and has a unique perspective: Before pursuing medicine, Dr. Schoppe was a private equity analyst.

Consider this transcribed interview a follow-up to my essay about private equity in medicine published a few months ago.

Here’s our (lightly edited conversation):

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Recommended Books for Radiology Residents

[This updated/revised article was originally published way back on December 21, 2013]

There are lots and lots of radiology books out there.

Rather than list oodles of options, I’ve made a short editorial selection for each section. There are obviously many good books, but your book fund is probably not infinite and you need to start somewhere.

First-year residents, in addition to Brant and Helms Core Radiology, might start with these recommendations prior to buying any additional texts that they are unlikely to read at length during their first exposure to each section.

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Recommended reading for first-year radiology residents

[This updated/revised article was originally published way back on December 12, 2013]

Expectations for first radiology residents include a whole lot of reading. Tons and tons of reading. The follow-through on that expectation may be somewhat less impressive, but you’ll still do your best to pretend. Given the dizzying array of options, a curated list of book recommendations seemed like a good idea.

With your limited resources, as an R1 I recommend first buying the general books that will serve you well throughout the year (and beyond). If you still have more funds, you can figure out what to buy next based on your interests and needs (and this list) after you’ve read what you’ve got. At that point, your program’s library (and/or unofficial digital library) will be a good place to see what’s worth your money. You’ll be doing a lot of your reading for free online anyway.

Last Updated April 2022. Since I initially wrote this list, I’ve also added an additional post on Approaching the Radiology R1 Year.

General goodness

The quintessential Brant and Helms’ Fundamentals of Diagnostic Radiology was historically gifted by many programs. Find out if your program still does so before buying your own copy.

The huge single edition looks better on a bookshelf but is cumbersome. It’s too heavy to carry in a bag and honestly too heavy to sit in your lap. Get the 4-volume edition if you actually want to use it. I owned the single edition, and as a result, I only really used the online access. And, to be frank, while B&H may be the classic introductory text, it’s overrated and definitely not uniformly good throughout. Too much text with too few pictures, often overwhelming for the junior resident. If your program doesn’t use it, I probably wouldn’t bother.

Core Radiology: A Visual Approach to Diagnostic Imaging is the “new” monograph (first published in 2013, its title shamelessly taking advantage of CORE exam dread and a pattern subsequently used in many radiology books since). It’s a better introductory approach than B&H for new residents (or those at the beginning of board review). It was finally revised for a second edition in September 2021, so it’s fresh. Bullet points, shorter paragraphs, bigger font, more diagrams, and (an initially) single authorship with tailored content mean that this volume presents a coherent and more practical approach than the old standby.

Aunt Minnie’s Atlas and Imaging-Specific Diagnosis is a fantastic quick read. It’s organized by section with a collection of classic “Aunt Minnie” cases that you must learn because they’re common or classic fodder for conferences and the like. Each section is short so you can spend an evening or two reading it at the start of a rotation.

Top 3 Differentials in Radiology is another quick, excellent general book. While Brant and Helms may have been the quintessential introductory text, textbooks don’t necessarily serve as the best introduction to day-to-day work. Each page presents a single finding (e.g. solitary pulmonary nodule), the most likely diagnoses with brief descriptions, and a few pearls.

The text that concisely supplies the radiology facts (but not the images) was classically the Primer of Diagnostic Imaging (the “purple book” aka “First Aid” for radiology), which has lists, outlines, and diagrams galore. It was historically well-liked but has the potential to cause death by bullet point (personally not my cup of tea), and I’d argue Core Radiology now handles this task better overall. A slightly cheaper, question-and-answer formatted alternative is Radiology Secrets Plus. In my opinion, these two volumes are more of historical interest and can be safely skipped.

One step up in terms of detail from Top 3 Differentials is Clinical Imaging: An Atlas of Differential Diagnosis, which is organized by a pattern recognition approach. It’s a huge, atlas-like book, which you may or may not be that interested in reading.

So, in my opinion, Core Radiology, Aunt Minnie’s, and Top 3 Differentials are three things I would buy at the very beginning, as they’ll serve you well throughout the year.

Some people like to start with textbooks. Others prefer cases. I think there is something to be said for cases and classic findings, which give you a sense of familiarity with the subject prior to digging into a dry textbook chapter. For every rotation, you could go over your atlas to get a grip on the anatomy, then follow it with the relevant sections of Top 3 Differentials and Aunt Minnie’s, and the combination wouldn’t take more than a few days.

Most books focus on pathology and rarely provide a practical approach for how to review studies in real life (i.e. how to develop a search pattern). It’s something people slowly figure out on their own or try to derive from attendings. One adjunct some might find useful for approaching different exam types is Search Pattern.

Anatomy

You can use a variety of free online atlases and tutorials as early anatomy resources:  UVA’s  Introduction to Radiology, Radiology Masterclass’s CT Brain anatomy, the very cool RAAViewer software, HeadNeckBrainSpine (RIP), FreitasRad’s Musculoskeletal MRI, Stanford’s MSK MRI, CaseStacks, Learning Neuroradiology, etc etc.

Good dead tree atlases include Fleckenstein’s Anatomy in Diagnostic Imaging (on the pricey side) and Imaging Atlas of Human Anatomy (on the affordable side, and well worth it for someone who wants a paper atlas). Sectional Anatomy for Imaging Professionals is more of an anatomy textbook, with descriptions, diagrams, and selected cross-sectional images.

The most useful overall is IMAIOS’ e-Anatomy, which is an excellent website and app available as an annual subscription. If your program doesn’t buy you access, you should come together as a residency and request it. Radiopaedia has supplanted StatDX in a lot of use-cases, but e-Anatomy is pretty clutch (though still painfully detailed in some situations and yet wimpy in others).

Physics

Physics may be essential for the boards (and life), but understanding MRI physics is the subset most likely to help you both interpret studies, troubleshoot technical challenges, and understand pathophysiology. Learning MR physics early will help you make the most of your MR rotations (if your program relegates you to reading plain films for your first nine months, then nevermind). My favorite introduction is the Duke Review of MRI Principles, which is surprisingly affordable for a radiology book and a must-buy content-wise. It’s quick and case-based.

Another fantastic MR physics book for the non-physics crowd is MRI made easy (well almost), which is old but relevant, out of print, impossible to buy, and very easy to download online. For the rest of physics, the cheap book is Huda’s Review of Radiologic Physics (Bushberg’s costs more and says more than you probably want to know; I’m not sure anyone reads it anymore in the era of the Core exam). You don’t necessarily need either. The RSNA modules are fine content-wise, but the online flash design/format is truly horrible and painful to behold.

Sectional

What books you should supplement with on each rotation will depend both on what rotations you have during your first year and how much reading you actually get done. A more complete list can be found here, but here are a couple of guaranteed hits:

On chest, Felson’s Principles of Chest Roentgenology is what you need to read for plain films. For cross-sectional chest/body, Fundamentals of Body CT is a more portable and readable replacement for Brant and Helms.

Call-Readiness

A new resource (as of April 2020) that I think is super neat is CaseStacks, a new subscription service that puts a ton of high-yield bread and butter cases with actual DICOM images and a serviceable web-based PACS that lets you actually experience real scrollable pathology as you do in real life (and not just an image or two as in most question banks). Each case also has findings (often including ancillary findings, like real life) and a pretty solid sample report, which will help you see practical examples of how to put some words on the page. I would absolutely have done this as a first-year or early second-year before taking call. (If my program had a subscription, I’d probably try to knock out the relevant cases first thing during the rotations like neuro CT as well.) As per my usual affiliate MO, I reached out and was able to secure you 15% off with the code benwhite.

What should I read as an intern to prepare for radiology?

Nothing. You can go in blind and not look particularly stupid.

That said, you can often pick up old books for ridiculously cheap if you want to get a headstart. Most of it won’t stick without having the volume of daily reading and dictation to put it into context.

A more useful book to read as an intern (any intern for that matter) is Felson’s, which is the book for plain film chest interpretation. Everyone should know how to do this. As a bonus, you may get to see how full of it some of your senior residents and attendings are “who read all of their own films.” Save the big book-buying for when you have a book fund to burn through.

If you’re really interested, you can hammer home some anatomy and familiarize yourself with basic radiologic pathology online. The Radiology Assistant is a really nice concise resource for a wide variety of normal and pathology. Radiopaedia concisely explains a great number of topics and has become the true Wikipedia of radiology. You can also browse the web and watch online lectures. Most societies have oodles of resources and free membership for trainees.

Once you’re ready for further reading, here is my compilation of highest yield texts for residents broken down by section/modality.

We’re hiring!

Well, not me/this little site.

But my organically-growing 100%-independent physician-owned radiology practice of which I am a partner/shareholder is hiring in most subspecialties including breast, body, neuro, neuro-IR, ER, and general. Basically everything except MSK and IR at the moment.

The market is hot, as I’m sure every radiologist and resident has heard, so we’re currently interviewing senior residents for 2023 starts as we speak, but we can accommodate folks finishing fellowship or out in practice if things are a good fit as soon as the credentialing ink dries.

I’ve written before about why I believe some job healthcare models are problematic, and why not all attending jobs are created equal. I’ve also written before about how to approach getting your first job out of training. My perspective and biases about radiology practice are on full display.

Our group was/is my first job out of training. I made partner last year and recently began serving on our board of directors. It was the job I wanted–so much so that the day I got the interview invitation email (after already having job offers waiting for a response), I did an actual Street Fighter dragon punch of victory and told the others they were going to have to wait past their response deadlines. I was drawn by two things:

  1. A well-established successful privademic model combining teaching-focused academics with the no-BS of private practice (with positions leaning more in different directions based on interest), which gave me the chance to teach and work with trainees in a more flexible environment than a traditional big academic bureaucracy. I’m currently the associate program director for our residency, and our residents are awesome.
  2. A sustainable job model combining high-quality (as opposed to only high-volume) radiology practice with reasonable daily expectations and the goal of a standard 4-day workweek (today is my day off!). I wanted the time and mental space to also be a partner at home and have the flexibility to do the other things that are important to me (like this). My colleagues are good at what we do, and I learn from them every day.

So if you’re in the market, come work with me and check out our great team in Dallas. If you’re interested, send me your CV at ben.white@americanrad.com and I’ll make sure it gets where it needs to go.

The ABR Lawsuit Continues

I thought after the last dismissal that the class-action lawsuit against the American Board of Radiology had died, but it continues.

Last week on February 16th, the “Court Of Appeals 7th Circuit” on YouTube (1.1k subscribers, in case you’re curious) streamed a brief 20-minute back-and-forth between the lawyers and the appeals court judges.

You can listen to the audio-only video on YouTube here (the ABR portion runs from 1:57 to 2:18, but that link should take you to the correct timestamp). In typical pandemic fashion, the ABR’s lawyer accidentally started off muted.

The case was heard by a panel of three judges. It is striking how short the oral arguments were: merely 20 minutes, and honestly barely enough time for the lawyers to do more than refer to the things they’ve written in the past and make mistakes.

The lawyers also seem incapable of addressing questions meaningfully. They either answer in circles or by restating points in ways that suggest that they may not actually know the answers.

I would not claim to have a meaningful understanding of the legal standing of the claim(s) against the ABR nor the ABR’s rebuttal to those claims, but you can read the most recent brief against the ABR here. Section titles under the heading “Statment of Facts” include such gems as “MOC is a Pure Money-Making Venture, for Which Monopoly Prices Are Charged, and Which Has Enriched ABR’s Coffers by More than $90 Million” and “There Is No Evidence of Any Benefit from MOC.”

If you’d like some background reading about the Sherman Antitrust Act, enjoy.

Fungibility

The initial judge seems to focus on whether MOC and other CPD (continuing professional development aka CME) products are fungible (i.e. mutually interchangeable), which of course they aren’t in the strict sense because the ABR has a monopoly in the certification market and no radiologist can choose to do anything other than be compliant with MOC or risk being unemployable.

From my reading, that’s sorta the whole point of the lawsuit.

OLA (ABR’s “online longitudinal assessment” program) may essentially be a CME product, but let’s be real here: Radiologists are not really paying the ABR for the OLA experience; they are–and have always been–paying for the credential.

“MOC” isn’t “Recertification”

There’s an interesting point where the ABR lawyer engages in historically inaccurate wordplay (at 2:08) saying that “recertification by its nature is different than MOC” because “it suggests that someone has to take a test to recertify,” whereas the ABR “chose a different path” in MOC because MOC “going forward post-2002” would require a “maintenance component, not recertification.”

This is super duper untrue because the switch to “time-limited certification” in 2002 was still very much the era when MOC actually did include a recertification test every ten years. The move to OLA didn’t take place until 2019, so the “different path” is a much much more recent fork in the road. (This is of course not to mention the simple fact that OLA functions as a test (taken in “tutor mode”) spread out over time with statistical assessment carried out after the participant answers 200 questions).

The ABR’s lawyer argues that Siva [the plaintiff] knew he had to do ongoing MOC when he got his certification as opposed to another exam-based recertification paradigm as she previously alluded to. But this is in fact also demonstrably false. Part of Siva’s initial complaint was that after passing the ABR’s 10-year recertification exam, he wasn’t given any credit toward MOC when the ABR started OLA in 2019. He did recertify. It didn’t matter how many years were left before your next test under the old (but still modern) system, you still had to do OLA (and pay the fees) on day 1.

At this point, a second judge asks the ABR lawyer point blank “what are the other MOC requirements [outside of OLA]?” and she dodges because she clearly doesn’t know. She says, “I believe that there are other components, but I don’t want to get too far outside of the allegations, your honor,” which is, essentially, I could bore you with the details but

He basically calls her out but doesn’t make her clarify.

MOC is Whatever We Say It Is

That same judge then goes on to bizarrely toss the ABR a bone and explains he was asking about the other components in order to parse the plaintiff’s argument against the ABR precisely because he believes it would be “extremely difficult” to argue that there is separate market demand for products “akin” to OLA.

This is an amazingly off-the-mark supposition in a world where there are several commercially successful products akin to OLA including multiple radiology-specific question banks (nearly all of which also predate the ABR’s OLA offering.) He then goes on to say he thinks radiologists are basically also paying the ABR for other random CME courses, which is also untrue.

Perhaps recognizing this friendly mistake about the uniqueness of OLA, the ABR’s attorney responds (paraphrasing):

ABR: no, that’s the wrong question because demand for OLA is irrelevant; it’s demand for MOC that matters, and MOC is whatever the ABR says it is.
Judge: “You can’t evade the substance of section 1 through the label [MOC], you know that…without using the label, what is the content of what you call MOC.”
ABR: …ABR is entitled to determine the content of its certification.

Essentially, the judge is trying to figure out if there is separate demand for some of the components of MOC, which is, of course, yes. But (but!) the ABR’s response: that demand is irrelevant because–to invoke the parlance of my people–MOC ingredients are only kosher if they’ve been given a hechsher by the authority of the ABR.

In real life, these are the quick answers to the judge’s query:

  • For OLA, as we just described, there is inarguably a robust market of radiology-specific question banks, most of which provide some assessment component and some of which even also provide official CME. These are largely analogous to the ABR’s OLA offering with the key distinction that the ABR doesn’t control them and profit from them. (And I suspect it is this desire to distance MOC from CPD that prevents the ABR from offering CME credits for the work required to do OLA despite very frequent requests from diplomates).
  • The non-OLA components are merely rubber-stamping the CME and QI/QA work that doctors basically have to do anyway. I think most people would agree it would be “extremely difficult” to argue that these provide independent value.

“That Cannot Possibly Be Your Position”

In response to the ABR’s it’s-my-party-and-I’ll-cry-if-I-want-to stance, the judge is flabbergasted:

“There’s no possible way…You can’t take the position that ‘we are the ones that certify and therefore we can define the content of the certification requirement without regard to the limitations of section 1 [of the Sherman Antitrust Act].’ That cannot possibly be your position”.

The ABR lawyer says no, but she’d just said that very thing and then literally reiterates it again in almost the same words.

This was presumably met with a long blank stare during the very pregnant pause in the audio.

So, she meant yes.

And the ABR is not entirely wrong, because MOC isn’t really a CPD product. The CPD part of MOC (OLA) is merely the veneer of credibility for the program. MOC isn’t really about CME.

It’s a tithe.

Conclusion

The reality is that every single person talking in that courtroom made statements that would be comically false to any practicing physician in any specialty and any participating member board of the American Board of Medical Specialities.

It’s no surprise that legal cases take forever, cost a fortune, and are generally unsatisfying. Over two years since the initial lawsuit was filed and the system still doesn’t even know the basic nuts and bolts of what recertification “continuing” certification actually requires and means for physicians.