As reported by Radiology Business, S&P has downgraded Rad Partners’ credit rating from B- to CCC+ (from vulnerable to speculative/junk)

The full descriptions of those ratings are here:

An obligation rated ‘B’ is more vulnerable to nonpayment than obligations rated ‘BB’, but the obligor currently has the capacity to meet its financial commitment on the obligation. Adverse business, financial, or economic conditions will likely impair the obligor’s capacity or willingness to meet its financial commitment on the obligation.

An obligation rated ‘CCC’ is currently vulnerable to nonpayment, and is dependent upon favorable business, financial, and economic conditions for the obligor to meet its financial commitment on the obligation. In the event of adverse business, financial, or economic conditions, the obligor is not likely to have the capacity to meet its financial commitment on the obligation.

As in, S&P doesn’t really believe RP can meet its debt obligations unless “favorable” conditions arise. I’ve reported on RP’s financial/PR problems before, including delays in profit-sharing just last week.

There was a great line referenced in the RBJ article that I’m not sure was intended as written or just an amazing Freudian slip (emphasis mine):

“That said, we also understand Radiology Partners’ cost saving initiatives, increased focus on organic growth rather than acquisitions, continued efforts to manage labor market conditions and ability to increase subsidies from providers, will eventually improve profitability and credit metrics,” analysts noted.

Assuredly RP is trying to get subsidies from its hospital contracts, but I suppose in many ways they are also keen on extracting subsidies from their radiologists as well.

Perhaps the recent management resignations (including the Senior VP of Finance and VP of Human Resources so far) are no coincidence either:

S&P said its downgrade also reflects RP’s corporate decision-making, which “prioritizes the interests of the controlling owners, in line with our view of the majority of rated entities owned by private-equity sponsors.”

You can read S&P’s announcement here.

I appreciate that not everyone is on Twitter—and frankly that’s probably for the best since it’s largely a toxic dumpster fire—but I did want to share this tweet/thread about a real situation unfolding at the American College of Radiology, the largest and most important radiology organization in the US. Among other things, the ACR sets standards for imaging center accreditation, creates the appropriateness criteria and incidental findings white papers we all love, influences reimbursement, and performs congressional lobbying on behalf of radiologists.

BREAKING: Did newly elected ACR board member violate election COI policy, failing to disclose that he works for @Rad_Partners? Here's a snip from the election manual indicating that he works for a medical school. Just another ACR academic insider, right? A thread…you decide. pic.twitter.com/6OANwAV8Yo

— American College of Radiology Partners (paRADee) (@ACRpartners) May 27, 2023

[Update: it looks like the ExitACR account got banned again. People involved in organized radiology like the ABR and ACR like to unfairly flag his/her content. The story shared in the thread was that RadPartner’s Associate Chief Medical Officer and head of Clinical Research and Education was elected to ACR leadership with his RP relationship functionally undisclosed to most voters.]

Insofar as anything involving organized radiology is newsworthy, this is news.

Who knows whether transparency here would have affected the election outcome. But we do know that this disclosure issue was debated fiercely a couple years ago, and this situation is exactly what people had in mind. I don’t know this radiologist, but it’s not just a paper relationship: he apparently went straight from the ACR annual meeting to be on stage at the RP Leadership Summit.

That said, this isn’t really a “private equity is just the worst” issue, because he apparently made the disclosures he had to make in order to follow the rules. It’s more of a problem/oversight with the ACR’s internal process compliance. However, it does reinforce how important these PE companies feel it is to infiltrate professional organizations (and especially to be high in the ACR leadership). It helps control the narrative and steer policy.

Every big democratic institution at least voices that it cares a lot about transparency and conflicts of interest. On that front, this is a big miss.

I posted two tweets the other day that deserve some further discussion:

RadPartners is now behind on paying its “unique” “profit sharing” proceeds to its “partners.” pic.twitter.com/KGCiTL87MK

— Ben White, MD (@benwhitemd) May 26, 2023

I’ve since by told by another source at RP that this is actually the third quarter in a row that profit-sharing has been delayed.

These “unique” payments are the ubiquitous practice of a group putting money in your 401k. “Profit sharing” is just the actual term used by the IRS. Practically, these contributions are just a portion of your compensation that is tax-deferred. For reference, my group contributes to my 401k on a monthly basis.

In other assuredly unrelated news, RP’s SVP of finance is resigning. pic.twitter.com/MbW3lOtDap

— Ben White, MD (@benwhitemd) May 26, 2023

Now, I am obviously not privy to RP’s internal workings, but I suspect these delays are twofold.

One, RP is suffering from cashflow/liquidity issues. That’s what they essentially say in the email snippet I’ve shared above.

Two, businesses have an incentive to delay payments/hold onto cash thanks to the time value of money: having money now instead of later is itself worth money—because you can invest it. By holding onto their radiologists’ money for longer, they can keep these funds earning interest, which helps their bottom line. This is a big reason why insurance companies delay care through denials and prior auths even for the things they know they will eventually cover. It’s also why Starbucks is basically a bank that sells coffee: they have over $1 billion in giftcards. Starbucks gets to invest all of that prepaid money before they incur the cost of actually giving you that delicious brown sugar oat milk shaken espresso.

The easiest way to make money is to have your money work for you.

RP needs (or believes they need) to do this now. Also note, these delays also started around the time RP laid off some of its nonclinical workforce.

This feels like part of a story.

When a “Partner” isn’t a Partner

The other word we need to address is partner.

It should almost go without saying that I can’t vouch for how every contract looks, but here’s the language for one of RadPartner’s “partnership” employment agreements:

Partnership Designation:
During the Term, the relationship between Physician and Practice shall be that of employee and employer and shall not modify or affect the physician/patient privilege or relationship. Unless otherwise directed in writing by the Chief Executive Officer of Practice, the Physician may refer to himself/herself as a “Partner”, allow others to refer to him/her as a “Partner” and refer to such other employees of Practice who have executed this Form of Employment Agreement with Practice as his/her “Partner”, provided, however, that the designation of “Partner” shall be in name only and the Physician shall not be an owner/partner of Practice under the law. Further, Physician shall not have any power or authority to bind Practice in any way, to pledge its credit or to render it financially liable for any purpose unless formally appointed an officer of Practice with such authority pursuant to Practice’s governing procedures and law or authorized in writing by the Chief Executive Officer of Practice.

You are a “partner” in name only.

This is the inescapable reality of choosing a “partnership” track job with an RP group. You are putting in the work in order to take on the responsibility of running the practice without actually owning the practice. It’s just verbal sleight of hand.

Evaluating “Partnership” Opportunities

Sometimes people reach out to me with employment offers and other quandaries for my opinion. (NB: Please note that I am a Person on the Internet and not an expert on most things including contract review).

A reader recently reached out asking for my thoughts on their partnership-track teleradiology-only employment offer with an RP-owned group. The offer included a decent workup salary with high productivity demands that I doubted most people fresh in practice would be comfortable hitting. As in, the W2 sounded very competitive on paper but was actually still pretty extractive taking into account the desired production. That’s not really news. All practices function this way at least to some extent. Partners make money on their employees.

The job also promised “full partnership” in two years with “equal profit sharing.” And this is the crux:

It’s true that whether you work at an independent practice or a private equity-owned group, the “profits” can always be zero. But the profits at an independent group are the profits (revenues minus costs). The profits at an RP group are something else. As United Healthcare argued in its recent lawsuit:

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.

An equal share of zero is still zero.

The stock offered to new RP employees is also almost certainly worthless. Don’t view the chance to catch a falling knife as a growth opportunity.

*  *  *

I promise I don’t begrudge anybody their career choices.

And you absolutely don’t need to consider what Random Guy with a Website says.

But if I were considering a job offer at an RP group, I would consider only the workup/employee salary and not make a decision based on the possibility of future increased income as a “partner.” I keep annoyingly using air quotes here for the same reason RP does: There are no partners. There is no partnership.

In each group, there are people who make less money and people who make more money, but they are all employees, and none of them are really actually entitled to much of anything. I won’t pretend to tell you what fraction of groups are happy with their sales and what fraction of groups are making good money and what, if anything, reliably differentiates the successful groups from the struggling ones. That kind of granularity is something that only RP knows, if anyone knows at all. But this much is undeniable: the partners are just employees who are usually paid more. 

*  *  *

If trainees flock instead to independent groups, then radiology private practice will stabilize and the independent model will survive. If they instead take one of the infinite positions offered by RP and their ilk, then they are casting votes for the corporate practice of medicine. I don’t have a crystal ball, but I remain concerned that the downstream consequences of that often understandable individual choice made en masse will be the tacit endorsement of the funding model and the acceleration of falling reimbursement and radiologist replacement.

If you want to work for RP, another PE company like Envision, USRS, or Lucid, or ride the current wave of teleradiology positions that pay relatively well, then you can do that. You don’t owe the field of radiology more than you owe yourself or your family. But it would probably be wise to assume that it is a temporary play and that some component of your job, either the money itself or the quantity of work asked of you, will change in the coming years. Radiology is in the middle of a nationwide shortage that will morph into a big unpredictable shift. Lots of radiologists change jobs, so you certainly won’t be alone.

Some of these are undeniably good employee positions right now. But don’t think for a second that a private equity partnership means you own the business. Because you don’t.

Here is the video for the American Board of Radiology’s town hall discussion about the new oral boards, which are coming to a computer near you in 2028:

Some highlights:

1. The ABR would like you to know that discussions about revamping the Certifying Exam started internally and “did not arise from an assumption that there was something wrong with the Certifying Exam.” (There is.) They did acknowledge that “nuance is lacking in the current exam.”
2. Any interesting formats such as simulation-based assessments weren’t possible due to “practical constraints.”
3. With regard to data about the effectiveness of either the old oral boards format or the current exams, Executive Director Dr. Wagner said: “We have no data that it DOES work.” He went on to say that proving the ABR exams have an impact “would be a difficult experiment to run.”
4. The initial timing will be during the second half of fellowships (first offered in 2028), but while the format is set, the timing would “not be hard to change” in the future if needed.
5. They will send out a “mock session” in the next few weeks apparently. I hope they also intend on releasing sample cases with sample scoring rubrics as well.
6. When asked about exam preparation/support from fellowships, Dr. Wagner said: “The ABR doesn’t really have a position on that, as to how a candidate should prepare.”
7. In the following discussion, the implication was that likely most preparation would take place during the fourth year of residency. It was not specified as to why it should be deep into fellowship (the phrase “the least bad choice” was used.) When asked why not just offer the Core and Certifying exams simultaneously or back to back, the ABR’s answer was that they were not interested in changing the need to pass the Core exam first in order to take the Certifying Exam, and the Core Exam takes time to grade. (But, yes, we could, again, in principle, just have written and oral exams like we used to.)
8. There will be no “hardcore” physics or non-interpretive skills.
9. The plan is for 7 25-min sessions with 10 min breaks between each. There will be an extra session (“recovery block”) at the end in order to deal with internet failures during the exam day.
10. The ABR currently spends more than $200 per item to develop its multiple-choice question collection. This exam won’t cost more, because no one will travel, the number of items is far smaller, and the judges are volunteering. In reality, this exam will be much cheaper. But also: no, they won’t be dropping fees.

Want more? Here is my initial discussion of the coming change.

ChatGPT’s newest version, GPT4, was able to pass a no-image multiple-choice radiology exam.

GPT4 is neat, but this says a whole lot more about how useless and off-base a radiology exam without pictures is than about how ready for prime time the current AI tools are. But they’re coming, and I for one am interested to see more natural language processing combined with what’s already out there to actually make healthcare more efficient (automated discharge summary drafts! a real summarized history on imaging orders!)

The authors also do note that when GPT4 is wrong, it’s often wrong in spectacular ways (and will boldly make up lies with the same confidence as it dishes out true answers). As in, not quite ready for anything when real performance counts.

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.Read 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.
Read More →