Stop Free-Dictating

There are many institutions/practices with well-defined “normal” templates for all types studies, which help provide a reasonable approximation of a house style. A clinician (or the next radiologist) has a reasonable chance of knowing where to find the information in the report. The reader can see something in the impression and quickly find the longer description in the body of the report for more information.

Templates can be brief skeletal outlines or include more thorough components containing pertinent negative verbiage. A section for the Kidneys could say “Normal” or it could say, “No parenchymal lesions. No calculi. No hydronephrosis.” Some groups have diagnosis-specific templates that build off a generic foundation to better address specific concerns like renal mass characterization or appendicitis.

Either way, some form of templating is critical to creating a readable report. After all, radiology for better or worse is a field where the report is the primary product, and creating reports that are concise, organized, and readable should be a goal.

Some institutions and practices do not have these baseline templates. There are (often but not always older) attendings who seem to not only practice but respect the freewheeling old school transcriptionist style of reporting. A resident who doesn’t “need” a template is to be prized and congratulated.

This isn’t 100% wrong either. It’s a useful ability in the sense that it’s important to be able to summarize findings in cohesive English. It’s largely the same skill as the casemanship skills used during hot-seat conferences that the recent Core exam generation of residents have largely lost, and so I can appreciate this perspective. However, at least from a reporting perspective, this is wrong in the 21st century.

 

The purpose of the radiology report

The first attending I ever worked in radiology was a neuroradiologist who posed a semi-rhetorical question on my first day. He used to ask:

What is the purpose of the radiology report?

The answer, he argued, was to create the right frame of mind in the reader.

I think this view is exactly right.

Defined in a narrow sense, this means that the reader should come away with the impression that you intend for them to have. If something is bad and scary, that should be clear. If something is of no consequence, that should also be clear. Items in the impression are there because we want those impressed on the minds of our readers, not just because we saw them.

With increasing patient access to radiology reports, we now have a second audience. While doing away with all medical and radiological jargon is probably misguided and unnecessary, we need to at least be cognizant of how our reports might read to a layperson (or non-specialist, for that matter). If we can be more clear and more direct, we have a greater chance of communicating effectively to all involved parties.

Templates make reports more organized, scannable, and readable. Not even debatable.

But while the primary intent of “frame of mind”-creation may relate to the significant radiological findings, it’s also about creating the right frame of mind about you, the radiologist. Thorough, thoughtful, organized, conscientious? Or rushed, disorganized, careless, apathetic?

There may be some perks of blinding readers with science and drowning readers in long-winded descriptions of even benign and irrelevant incidental findings. At least you won’t look lazy! But for the less verbose among us, we can show we care by creating reports that reflect our systematic approach and clear writing style. Templating is critical to creating digestible reports.

Lastly, as quality metrics rise in importance and resource utilization re-enters the arena as a responsibility of the radiologist, we also need our reports to be readable and indexable by computers. The easier our reports are to parse, the easier we can extract meaningful data about our findings, link these up with patient data from the EMR, and draw high-powered conclusions about patient impact, outcomes, and (of special importance to me) the utility of certain exams in specific clinical contexts.

 

Dictation software is a tool, not a recorder

If you’re a resident somewhere and your institution doesn’t have power normals to frame-out your reports, make some. If you find yourself saying the exact same things over and over again every single day, then you’re doing it wrong. It should either part of the template or an auto-text macro. If nothing else, it will reduce your rate of transcription errors.

No one needs to reinvent the wheel on every case!

The ABR’s new Online Longitudinal Assessment (OLA)

It was super duper gratifying to receive my first OLA email from the ABR this past month. OLA (Online Longitudinal Assessment) is the ABR’s new longitudinal MOC (Maintenance of Certification) process, where diplomates take 52 questions every year instead of a big test every decade.

I took the Certifying Exam in October and received my passing result in November, so the month-long break prior to needing to “maintain” my brand new certification from the ABR feels just about right. Yes, a thousand folks need to maintain a piece of paper they haven’t actually received in the mail yet. I can appreciate why folks fresh off their q10-year MOC victory are irritated at needing to immediately participate in more MOC. Promises are being broken left and right. But, hey, money.

Adding insult to injury, as a neuroradiologist, I still have to sit for the exorbitantly expensive ($3,270) neuroradiology subspecialty exam this October. Which means that I need to maintain my first certification in between getting my second.

The final irritant in this system of paying $340/year (forever) is that the ABR, which is a nonprofit sitting on a war chest of ~$48 million, didn’t apply for (i.e. pay for) ACCME accreditation, so the hours spent doing OLA questions don’t count as official CME.

 

The Actual OLA Experience

The current OLA paradigm is that 2 questions are released every week (104 a year) and “expire” after 28 days. So while you can log in and batch around 8 questions a month, you won’t be able to do it less often without losing some expired questions. Since you only need 52 questions and can do around 8 a month, you could actually get away with doing it almost bimonthly.

I took my first 8 questions this week and got them all right. They were straightforward, reasonable, and relevant to practice (at least in neuroradiology). My initial impression is that OLA questions are more like what the Core exam should be. You get between 1-3 minutes per question, the website was pretty slick (at least on a desktop), and I did all 8 in around 5 minutes. Can’t complain there. This is clearly a better system and more logical way to fulfill the spirit of MOC than taking an exam full of (even more) irrelevant material every decade.

You get to choose your practice profile and thus what types of questions you receive. I originally chose general diagnostic radiology and neuroradiology, but out of my first 8 questions, 7 were neuro and only 1 ended up being general, and the general question concerned GI fluoroscopy, which I detest, so I switched to 100% neuro. Maybe it’ll help with the subspecialty exam.

 

Things the ABR should improve:

  • Mobile experience. I’ve heard complaints about display issues on phones. You only get a minute for most questions, so it needs to work.
  • Lower the price. At the current rates, this is far more expensive than any commercial qbank. And that’s what this is. The ABR makes a lot of profit for a non-profit.
  • Increase the question-life. Why do questions expire after 28 days? So arbitrary. Let the radiologists hold themselves accountable. How about 90?
  • Get official CME accreditation. This feels like apathy and laziness. I know it’s not straightforward or cheap to be a CME-granting organization with the ACCME. But again, this is an expensive process, but it would be far more reasonable if it counted for CME.

And finally, how about you let everyone take the certifying and subspecialty exams using the OLA software instead of flying out to Chicago to waste their time?

Pitfalls of Private Equity Takeovers

You may have heard about this absurd story in the NYTimes a few months ago: An academic journal pulled a legitimate article comparing practice characteristics of groups that take on private-equity funding and those that do not. Why? Because a PE firm put the squeeze on their editor, that’s why:

In an interview, Dr. Hruza [the incoming president of the American Academy of Dermatology and board-member of United Skin Specialists, the largest PE-backed derm practice in the country] said he did not ask that the paper be taken down. He did, however, confirm that he expressed his concerns to Dr. Elston, the editor, after it was posted. Two days later, Dr. Elston removed the paper.

From the reporting in the times, this situation is absurd. If people have quibbles with the conclusions of a peer-reviewed article, then they should write a commentary. You don’t get to line-edit someone else’s manuscript.

Dermatologists account for one percent of physicians in the United States, but 15 percent of recent private equity acquisitions of medical practices have involved dermatology practices. Other specialties that have attracted private equity investment include orthopedics, radiology, cardiology, urgent care, anesthesiology and ophthalmology.

PE firms are following the money. However, their primary objective of extracting profit doesn’t necessarily equate with an understanding of how to actually run a successful, responsible, and sustainable medical practice.

Dr. Konda, [the paper’s lead author], said he first grew interested in the topic when several of his trainees went to work for private equity-backed practices and told him of clinical environments that emphasized profits at the expense of patient care.

 

With that preamble, check out this interview with radiologist and former PE analyst, Kurt Schoppe, MD on Radiology’s Nearest Threat, Commoditization, and the Misguided Notion That You Will Be Paid for Everything You Do.

 

Lots of excellent responses, but these three quotes give you a nice flavor of private-equity takeovers in broad strokes:

One of their favorite marketing lines is “physician-owned or physician-operated.” That’s really a misdirection because, frequently, they set up a holding company under which the physician group is a wholly owned subsidiary. Yes, the physician group is owned and operated by physicians, but it is not controlled by physicians because, as a wholly owned subsidiary, the parent corporation, or the holding company, is going to have absolute control. That holding company is not majority-owned by the physicians. The wording on the contracts is going to be such that the PE firm or the corporate entity is going to have control over the parent entity when it needs it.

What I’m getting at is no matter what the marketing says, no matter what they are telling people when they are selling services, these entities must make money for their owners/investor as their primary objective. Changing the economics of radiology group ownership is not fundamentally about the patients or saving money for the payers. They do these things to make money for their investors. This is not a negative judgement, it’s just a fact. If physicians want to sell their practice, if someone is only 4 or 5 years from retirement, and they only have a 4- or 5-year hold on their contract after they sell their group, well, that is just logical. From a purely personal economic point of view, it makes sense for them to sell, because they are not looking at a 15- to 20-year timeline.

The people who need to look out for this are the people in training, the people coming out of training, and the younger physicians in the group who have a 15-, 20-, 30-year timeline. If your goal when you came out of medical school was caring for patients, positively affecting the health care environment, or doing things for the greater good, I think you are better able to do that as a physician group in which you decide, as a group, how much money you need to make, what sacrifices you choose to make, and for whom you will charge less. If you cede control of your decision-making to a group that will only be motivated by its ability to make returns for its investors, you’ve put someone else in that conversation who does not necessarily share your values and ethics as a physician.

Anyone joining a hot-bed field like dermatology or radiology needs to understand the business model of your chosen profession and evaluate the health of both the practice and local market you consider joining.

While partners may get short-term windfalls in some buyout scenarios, non-partner employees are the primary profit source. Spending time in a partnership-track without eventually being a partner is a waste if the position becomes untenable and you need to start fresh somewhere else.

Review: Proscan’s MRI Online

MRI Online is an advanced (MRI focused) online radiology video platform offered by Dr. Stephen J Pomeranz, who is primarily a musculoskeletal radiologist. Just one dude. This in contrast to most online offerings in radiology, which are typically recorded board reviews or CME lectures from the big popular courses at places Stanford, Hopkins, Duke etc. Multiple folks talking about multiple topics. Those production values tend to be relatively low because they’re typically recorded from normal in-person talks with the best of intentions (but without the best of audio engineering).

I was recently offered the chance to check out MRI online. I had the intention of spending time with it to help with studying for the certifying exam, but then I ended up not studying. That’s a separate story.

Anyway.

Content

There are several different kinds of content: “Mastery series” lectures are divided into digestible 5-10 minute chunks. “Lecture series” are more typical hour-long lectures (some of these are a bit older). “Courses on Demand,” which are recordings of in-person case reviews (my least favorite). And lastly, “Power Packs,” which are interactive PACS-integrated cases with questions and explanations (but no video).

Platform

MRI Online uses the Teachable platform, which is basically what every new course you’ve seen advertised on Facebook uses. Teachable is simple to use, especially well-suited for video courses, and produces a clean product, so there’s no secret why.

There are pre- and post-tests available, but these tend to be short little multiple choice deals (often text-only). Nothing special there. This is definitely not aiming to be a q-bank.

More importantly, Teachable videos have the ability to be sped up, so you can pick your pace accordingly.

What separates MRI Online from just about every other product out there is that the case review components are integrated with an online PACS. You can review the cases (scroll through stacks, multiple sequences, window/level, etc.), read them cold, and then essentially go through them with Pomeranz or with a written explanation. It’s interactive. It’s practical. It’s reflective of real practice. It’s basically like being a resident or fellow, except that you’re on your own pace, the cases are carefully curated, and your teacher isn’t too busy to teach. It’s pretty neat.

Pricing

Pricing is a bit of a mixed bag.

The in-training price is actually pretty reasonable ($50/month or $500/year). In particular, if you have plans to do an MSK mini- or real fellowship, going through MRI Online would be a great introduction and much less painful than Requisites. For cost reasons, I think any trainee is probably going to buy on a month by month basis when they have time and not to fork out for the year.

(Talk about responsive, the price for fellows used to be $100/month. When I commented that fellows don’t really make significantly more than residents, they dropped the price a week later)

While there’s also a lot of content for neuro (and some prostate), I think most people probably wouldn’t need to buy more than a month if your focus is non-MSK. Proscan tells me they’re adding tons more non-MSK content this year, so I imagine that’s likely to change.

The price for folks out in practice gave me a bit more sticker shock at first: $150/month or $1500/year. That said, you do need CME, lots of practices do provide CME funds, and course reviews and conferences are generally even more expensive and not amenable to pajamas. MRI Online provides real ACCME CME credits, which for the price are actually a bargain depending on how hard you pound your subscription.

I wouldn’t pretend to have the ability to compare and contrast any of the huge number of course reviews that exist in radiology, but MRI Online is definitely better than a lot of conference talks I’ve gone to at RSNA, ASNR, WNRS, ABCD, and WXYZ.

Here’s where the usual negotiated discount/affiliate stuff comes in:

Code BW_TRAINEE gets you 10% off ($45/month or $450/year) and BW_ATTENDING gets you 10% off ($135/month or $1,350/year).

The annual subscription also includes a free MRI anatomy atlas as well as free attendance at a 3-day MSK MRI course held annually in Cincinnati. They tell me the vast majority of subscribers are annual, not monthly.

Free Samples

There’s a free online MSK mini-course with a sample of cases (that you would need to sign up to take).

There are also sample videos for each course (e.g. shoulder, hip) that you can watch without logging in, as well as sample cases for basically every course. You’ll get a history, review the cases in the diagnostic viewer, then answer a multiple choice question about them. The explanations have annotated lesions and a relatively concise readable description.

They also provide a full free 7-day trial, which is a real steal for trainees or for focused test-prep.

Bottom line is that there are plenty of no-risk opportunities to check it out. There’s lots of totally free content and no bait-and-switch in sight. I wish more companies were this transparent.

Conclusion

MRI Online is actually an impressive and pretty expansive product, particularly for MSK, but also with hours of content for neuro and body. In addition to solid review, I’d definitely consider signing up again if I changed practices and needed to expand my toolset.

Journey to the ABR Certifying Exam

If there is little information online about the ABR Core Exam, there is essentially none about the Certifying Exam. After several years, the only nuggets on the grapevine were that it was easy, nobody has ever failed, and you might as well do all your selected modules in the field of your fellowship.

All of that is probably true. But just as diagnostic imaging for pulmonary embolism in the ER is always indicated, more information is always better, right? Continue reading