I once had an attending describe a finding as “mild to moderately severe” https://t.co/yF8Ccanude
— Ben White, MD (@benwhitemd) March 4, 2023
First, undoubtedly, we need to flesh out the bottom of the scale to include nominal < trace < minimal.
Then if we give partial gradations like my old attending (not just moderate, moderate to severe, and severe but further subdividing fractions of each!), then we can truly attain radiology nirvana.
Here are some thoughts from a seasoned radiologist who was there for the sale and just bailed from an unhealthy private equity-owned radiology practice. They’ve seen many trainees filter through the recruitment process recently as the group aggressively recruits to combat attrition, and they reached out with some brief advice on how to approach the contract/job when evaluating the offer to join a similar practice.
Their perspective is in the blockquotes, and my commentary follows.
As with most of the work on this site discussing private equity, most lessons and pitfalls are not unique to PE. Private equity is a funding model; no organization has a monopoly on unsavory business practices, and every contract requires scrutiny.
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You need to know what exactly was sold. The most accurate assessment would be in terms of a percentage and the understanding that X percentage of your future earnings have been sold.
When taking an employee job, your compensation is isolated from this calculus. You’re being paid what you’re being paid. The reason it matters? If the partnership is unstable because compensation is too low for the degree of work relative to the market, then the group is or will likely be unstable. In the short term, that may mean being asked to work harder or the job being less pleasant. In the long term, that may mean being back on the job market.
If you’re taking a “partnership”-styled job, there will eventually be a “profit-sharing” component; now it really matters, because your “bonus” can be $0.
Traditionally you would be given information and have a good reason to believe what you’ve been told. But to a staff-starved organization, you need to be careful.
Even in a stable group, staffing needs may change. In an unstable one, they may change dramatically. You may be asked to cover additional sites or different practice settings. Your income, once a “partner,” may change. When things get very tight, you may not be able to use your vacation.
In some settings, you may be insulated from these shifting demands during the work-up. Once a partner, a bump in compensation will shackle you to dealing with the problems. You may even, rarely, be paid less per work unit than as an associate.
PE contracts will often state a salary with specifics like bonus and vacation TBD by the local practice board. When doing so, notice you’ve got nothing in writing beyond your contractual salary. By splitting these variables in a contract there’s little responsibility. You need to get hard numbers in the contract to protect from time off takeaways or continually shockingly low bonuses.
One of the most helpful things may be to ask for a copy of the employment agreement. This will allow you extra time to scrutinize and ask questions before the clock on an offer starts ticking.
Many institutions actually employ a similar tactic where you’ll sign a relatively boilerplate employment agreement and receive a separate, shorter, often more plain-Englishy document that will include the details. That second document—sometimes called a Letter of Understanding (I discussed this more here)—will often include qualifiers like ‘this is what people in your section do currently’ or other weasel words to allow those details to change as needed.
Keep in mind, this isn’t always nefarious. To give you a personal example, I’m a partner in a great group. During my workup, we had to adjust our call coverage hours at the hospital a bit and that changed how my division scheduled our call. These contract structures allow those operational changes to happen without requiring a contract negotiation or a signed addendum for every small detail change.
If you’re a strict employee and expect to be dumped by the group when times get tough, it’s more reasonable to want everything you care about in writing.
Some groups may tout a salary that’s purely wishful thinking. One thing to help assess is to ask for W-2 forms for a partner and/or associate. If there’s a big delta between hope and historical income…caveat emptor.
Note that some PE groups have offered their franchises 0% loans which would increase W-2 numbers. Fortunately, I’ve heard of no groups taking up this deceptive practice to artificially inflate incomes.
That last part is a very sneaky move and bears a bit more discussion. We’ve discussed previously the relative ease with which a corporate entity can temporarily fund supra-market compensation for a position through debt instead of operations (i.e. using borrowed money to take a loss on an employee in order to get the work done).
I’d not heard of this new play before, but this would be a related but different move: by giving the group money to play around with, the PE owner can flush a practice with cash and make them look more successful and better paid than they really are. This would, of course, be a temporary move. Taking a partnership-track job in a practice that took a loan like that would likely result in the future partnership salary being substantially lower than you’d have expected.
RVUs: What are they and why are they important? The relative value unit is the value CMS assigns to different CPT codes to determine payment for a ‘unit’ of work and allows for variable value/compensation for work across the medical spectrum.
Not all things are equal for example. Some radiology examples: CT brain w/o contrast ~0.85; MRI brain w and w/o contrast ~2.29; CXR ~0.22; CT abd-pelvis with contrast ~1.82. One good way to assess compensation is $/rvu.
My personal rough considerations:
<$20: Horrible deal for the radiologist. Someone is getting the technical fee and a large chunk of your professional fee.
$20-29: suboptimal, losing some of the interpretation fee
$30-40: close to full or full professional fee
$40-50: full professional fee
$50+ is an excellent payor base and or some technical fee.
For background, the other components of a CMS payment are the conversion factor (which is what keeps falling every year, currently 33.89 in 2023) and the geographic practice cost index (GPCI, which is an adjustment for locoregional cost factors). For our purposes, we’re ignoring the MIPS quality program. When people discuss RVUs, they are often referring to the wRVU (the work RVU related to physician effort), but there are also peRVU (for practice expenses) and mpRV (for malpractice expense).
Reimbursement for the professional component = [(wRVU*GPCI) + (peRVU*GPCI) + (mpRVU*GPCI) * CF]
For example, the GPCI in Dallas where I live: Work = 1.018; PE = 1.009; MP = .772 (malpractice expense is “low” here thanks to tort reform).
So for a brain MRI with and without contrast, this year Medicare should pay: [(2.29*1.018)+(.85*1.009)+(.13*.772)]*$33.89 = $111.47
Compensation per RVU varies a lot by region and payor contract, so, again, an apples-to-apples comparison is challenging to obtain but important to attempt. A big component of how much you make is how hard you work, but it’s not the only metric.
You also have to distinguish between working as a partner/shareholder and an employee. Historically, a person in the workup is going to be relatively low as part of the so-called sweat equity (i.e. earning their place as a shareholder). So when attempting to figure out a fair partner compensation per RVU, you can see what CMS pays per RVU as a lower-end reference rate. A group’s real-life take-home per-RVU compensation has so many nuances: payor mix, percentage of bad debt, the (increasingly uncommon) share of the technical component, billing expenses, other overhead, etc. No group or individual radiologists is simply earning per hour the total of everything they bill, even before the PE group loses a big fraction to its owner.
When evaluating a job, a per-RVU number like this is a helpful shorthand for comparison, but unless you’re taking a mercenary job and actually being paid per RVU or paid per shift (with a strict productivity requirement), then things can get confusing. Every group has its own compensation plan, and it’s surprisingly difficult to infer fairness from a simple number. It therefore works best when comparing jobs in the same local market or when comparing teleradiology positions.
In the workup, this $/RVU number is going to change over time as your salary typically grows every year, and it will also be different for partners. Some people are faster or slower, and depending on the group’s compensation plan (i.e. unless there is a very strong productivity focus), that means people who are slower/less productive tend to be paid more per RVU.
Different groups also have very different benefits. If your group is flooding your 401k, putting money in your HSA, good healthcare, etc, it’s not always as simple as dividing your take-home pay by your total RVUs or dividing your per-shift compensation by your daily RVU requirement and seeing the number. It’s a useful shorthand, but it’s still only one tool in your arsenal. It is important to keep in mind, however, because it’s easy to hide a lot of suffering in what seems like good compensation and good vacation if you’re reading a ton of RVUs per shift.
Don’t discount high-RVU demands. There are a lot of radiologists working much harder on a daily basis than they ever did taking call as residents. If the comp seems too good to be true, the higher salary may just end up being golden handcuffs.
This is a huge sign of group health. There are two types: topside and bottom. Off the top, older/end-of-career isn’t all that concerning. But bottom-side, younger rads with decades of career left, is a tell. At my group, the number of associates at the time of sale was close to 50. Soon there will be single digits remaining. Applicants would be wise to ask for and speak with young radiologists who have left the group to get a 360 perspective on the organization.
This is true. The one caveat I will add is that job mobility is and has been common in radiology for quite a while. So while an exodus is a real problem, a little context will be needed to understand the situation and the stability/trajectory of the group. As I’ve referenced before, a recent 2020 study showed 41% of radiologists had changed jobs in the past four years. Motion is common, so look deeper. A couple of folks leaving may be no big deal just as easily as a harbinger of doom, especially in the current job market.
You should absolutely know specifically when the vesting period ends for the legacy partners. No one has a crystal ball, but it would be prudent to operate under the assumption that when that time comes, there will be a bolus of people leaving/retiring and the group will never be the same.
This a great opportunity normally. But many PE groups are using this as an income growth model. We bring in extra work which you can do and make extra money. Sounds good right? Sure–but it needs to be viewed from the perspective of the primary 8-5 job income adequacy. If young folks are having to sell their time off, take extra jobs or side gigs, then your primary job is inadequate and probably too much of the group was sold off.
Internal moonlighting is great, and it’s very common for folks to supplement their income this way. But it’s different when it’s mandatory, and it’s different when the numbers from internal moonlighting are being used to prop up W2 and make the group look more successful (“we’re making X per year,” when X is a number inflated by lots of work after hours). Moonlighting may be fun and desirable when your daily demands are reasonable; it may be pure burnout on top of barely achievable productivity requirements or lots of call.
In order to do an apples-to-apples comparison, you need to be able to break total compensation down into its components (e.g. salary, call, moonlighting, bonus, 401k profit-sharing) and see how many hours people are putting in.
The break-up process should be scrutinized, specifically tail insurance and non-competes…if you take a job that winds up being $100k’s less than what was advertised and you want to leave, you need to know if you’ll get hit with a hefty tail insurance bill or have to move to avoid a non-compete.
It is still generally common in groups of all stripes for the radiologist leaving to be responsible for tail coverage on a sliding scale over time, paying more if you leave quickly and paying nothing after being there for several years.
Overall, the particularly onerous break-up conditions from PE-owned groups have significantly softened as the job market has become more competitive. Anecdotally, I’m not even sure at this current timepoint if they are “worse” than independent groups. Things I’ve been hearing recently seem comparable from that front. There’s a decent fair range here, and—as with all things—must be judged on a per-group basis and put into the overall context. Ideally, you’d pick a job that you’re less likely to need to bail from in a short timeframe to begin with, but it seems like a good idea when considering a PE-owned practice to be able to pack your bags without feeling locked in.
What I have seen a lot recently is more and more people leaving these groups to stay physically where they are and take on teleradiology work. It seems that this is often a combination of not wanting to move their families and waiting out non-competes. People leaving are in a fortunate situation at least that there is a way to make a living online these days.
Where to work is an important decision, but it is nonetheless a reversible one.
The American Board of Radiology came to the Texas Radiological Society annual meeting this past weekend and presented an update.
Some things have changed recently. For example, the ABR is now handling all remote-proctoring in-house instead of using Procturio.
Something things haven’t really changed: You still have to do your MOC OLA in small batches at a pace designed to emphasize its longitudinal nature.
And the initial certification process will change, though it’s currently unclear how.
Last year, the ABR conducted a stakeholder input survey about initial certification (i.e. the Core and Certifying exams). This slide was their summary of those findings, which is a compellingly honest accounting of the current situation:
Multiple choice questions (MCQ) can adequately (though not optimally) assess knowledge, but the overall process is a poor measure of clinical competence as it pertains to interpretation skills, communication skills, and professionalism.
I think we can all agree with that conclusion.
They then went on to (vaguely) describe their ongoing process to evaluate potential solutions. They plan to announce proposed changes in June 2023 (though potentially earlier in April, even).
Reading between the lines, it sounds like the ABR plans to focus on changing the Certifying Exam component of the initial certification duo, as they basically acknowledged that they have a hard time justifying the post-training Certifying exam as providing any additional value when it’s functionally just an awkwardly timed and arguably easier version of the same test people already took. Even the NBME realized that USMLE Step 3 had to be at least partially different than Step 1 and Step 2 if it was going to pretend to be anything other than a money grab.
Whether the ABR is able to make the Certifying Exam usefully different or just demonstrably different is of course another story entirely. Doing what I have suggested and focusing on radiology simulation isn’t easy.
Current residents, if that scares you, no need to fret:
ABR committed to providing at least 5 years’ notice before any substantive changes with be implemented in the DR Initial Certifying process to ensure that residents currently in training are not impacted.
We are a lifecycle away from any change.
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.
I asked Poe, a new AI chatbot, to write me a sonnet about a negative CTA for vertigo:
A CT scan of the head and neck was done,
To search for the cause of vertigo’s plight.
But alas, the results came back as none, No evidence of any wrong or right.The images showed the structures so clear,
The bones and vessels, all in their place.
No sign of tumors, no sign of fear,
No cause for vertigo’s dizzy chase.The scan was negative, the results normal,
The cause of vertigo’s still unknown.
But rest assured, there’s no need to mourn,
For further tests will surely be shown.So let us trust in the power of medicine,
And hope for a cure with each new exam done.
“Further tests will surely be shown” is some (awkwardly phrased and presumably unintentional) incisive commentary on American healthcare.
From Matthew Davenport’s upcoming article in AJR, “Incidental Findings and Low-Value Care“:
It is increasingly recognized that incidental findings are incompletely understood, expensive, and surprisingly harmful. Rather than a benefit of imaging, they are usually a harm. They are not sought, the odds of them being important is low, and they create tremendous uncertainty and low-value care.
A good primer on an often unintuitive and yet incredibly important problem in medical diagnostics (both for radiologists and clinicians).
For those who want to listen for almost an hour about PE in radiology, the current radiologist shortage, and navigating the job market, I was on the BackTable VIR podcast.
A few years ago I published my deep dive into the bylaws of the American Board of Radiology. Bylaws are boring, dry documents that most people don’t care about and even fewer read. But they do shed light on the culture of an organization and its priorities. The ABR’s were comically nefarious. For example, their old conflict of interest policy (emphasis mine):
It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by a Governor serving on the Board of Governors of this Corporation requires the Governor to act in the best interests of this Corporation, even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member. Consistent with a Governor’s duty of loyalty, a person serving as a Governor of this Corporation does not serve or act as the “representative” of any other organization, and his or her “constituency” as a Governor of this Corporation is solely this Corporation and is not any other organization or its members.
The ABR approved an update to their bylaws on November 2, 2022 (available here), and they’ve finessed that bit by removing the bolded language above. It now reads:
It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by an individual while serving in the capacity as a member of the Board of Governors or Board of Trustees requires the individual to act in the best interests of this Corporation. Consistent with the duty of loyalty, a person serving as a member of the Board of Governors or Board of Trustees does not serve or act as the “representative” of any other organization, and said member’s “constituency” as a member of the Board of Governors or Board of Trustees of this Corporation is solely this Corporation and is not any other organization or its members.
So they’ve removed that choice verbiage requiring selling out radiology itself in the interest of the ABR: “even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member.”
Good for them.
On a related note, in case you’re wondering, the composition of the “executive compensation committee” is unchanged:
Executive Compensation Committee. The Executive Compensation Committee will carry out the Board of Governors’ responsibilities for designing, managing and annually reviewing Executive compensation and the Executive compensation policy. This committee will consist of the President, President Elect, and at least one (1) additional member from the Board of Governors appointed by the President. The President will chair the committee.
As I mused in my previous post:
I love that the committee that handles executive compensation is chaired by the president and then attended by the president-elect and “at least one additional” presidential appointee. Good thing that a conflict of interest for the ABR is just when a Governor cares about something outside of the ABR.
I had a brief chat with OpenAI’s ChatGPT about noise, radiology, and AI in medicine:
Human: Summarize the book Noise by Daniel Kahneman
AI: Noise by Daniel Kahneman is a book that examines how our minds work in a noisy, uncertain world. It dives into the cognitive biases and heuristics we use to make decisions with limited information, and explains how they can lead us astray. The book covers topics such as perception, intuition, and decision-making, and explores how noise and confusion can shape our lives and our thinking.Human: How does the book argue that noise impacts radiology?
AI: In Noise, Daniel Kahneman argues that noise can have a major impact on radiology. He explains that radiologists are often subject to cognitive biases like confirmation bias and anchoring bias, which can lead them to make decisions that are not in the best interest of their patients. Additionally, he shows how noise can affect diagnostic accuracy and decision-making, making it harder for radiologists to provide accurate treatments and diagnoses.Human: How could radiology address those limitations?
AI: Radiologists can address the limitations of noise in radiology by taking steps to reduce cognitive biases and increase accuracy. These steps include utilizing evidence-based decision-making, double-checking results for accuracy, and employing advanced imaging technologies such as computer-aided detection systems. Additionally, radiologists should strive to keep up with advances in medical technology and imaging techniques so that they can identify any noise or errors in their images.Human: What are the current limitations in utilizing AI in radiology?
AI: Currently, one of the biggest limitations in utilizing AI in radiology is the potential for errors and false positives. While AI systems have the potential to be more accurate than human radiologists, there is still a risk that the AI system will miss diagnoses or misinterpret images. Additionally, AI systems can be costly to implement, and require significant computing power, which may not be feasible in many medical settings.Human: What would be the easiest type of medicine to outsource to AI?
AI: The easiest type of medicine to outsource to AI would be administrative tasks such as scheduling appointments and completing insurance forms. AI can quickly and accurately complete these types of tasks, saving time and resources for medical professionals.
Even the machines think there’s some low-hanging fruit out there.
The bylaws of the American Board of Radiology are interesting. I’ve written about them here, and you should read that post. Go ahead, I’ll wait.
Relevent to an email blast the ABR sent out this week is section 4.3:
Section 4.3. Election of Governors. Nominees shall be solicited from the Board of Trustees and Board of Governors, and may be solicited from any appropriate professional organization. Professional organizations shall provide such nominations in writing. An affirmative vote of at least three-fourths (3/4ths) of the entire Board of Governors shall be necessary for the election of any nominee to the Board of Governors.
The Board of Governors is the main decision-making body of the ABR. Historically, as you might surmise, it’s been a pretty insular group. The people already in charge nominate their friends and colleagues, most of whom have already put in the time and effort to earn a place in this upper echelon through years of service to the organization.
As I wrote in that post:
If you didn’t know, there are currently 8 Governors, and they basically run the show. Lincoln’s famous “team of rivals” approach this is not. The current people in power shall nominate their replacements and other organizations may, but the key for any hopeful member is making sure that you fit in with the cool kids, essentially guaranteeing that no one with substantially differing views would ever make it to the upper echelon.
On November 7, the ABR sent an email out to all diplomates (people who are board-certified):
The American Board of Radiology (ABR) is seeking interested candidates to serve on its Board of Governors. The Board of Governors discharges the fiduciary duties of the Board through its oversight of the business and affairs of the ABR.
The ABR recognizes the benefits inherent in a diverse community and seeks individuals with varied experiences, perspectives, and backgrounds. Interested candidates must be board certified by the ABR and willing to participate in Continuing Certification (MOC). Those from nonacademic practice environments are especially encouraged to apply.
And the nomination process for those interested candidates?
Nomination Process: Interested candidates should send a curriculum vitae and a letter of interest before November 15, 2022, to Brent Wagner, MD, ABR Executive Director (bwagner@theabr.org).
How about that.
Now presumably the actually election process is still the same (as is the impressive Conflict of Interest policy), but I believe this is the first time the ABR has publicly asked for all-comers. Now that doesn’t mean they’ll actually take any of those candidates seriously or that such candidates would ever comprise more than a single spot on the board, but—nonetheless—I would encourage anyone interested to apply.
In August, the results of a large ACR survey about radiologists’ opinions concerning MOC were released. The summary:
Similar proportions judged the existing program as excellent or very good (36%), or fair or poor (35%), with 27% neutral. MOC–CC was perceived more often as excellent or very good by those who were grandfathered yet still participating in MOC, were in academic practice, were in an urban setting, were older, or had a role with the ABR. In contrast, MOC–CC was more often judged as fair or poor by those who were not grandfathered, were in private practice, were in a rural setting, or were younger.
It’s a pretty sharp divide. Perhaps it is no great surprise that ABR volunteers and grandfathered academics are among those who view the ABR’s offering most favorably. The whole paper is worth a read, and the survey construction itself was very involved.
I’m not personally involved in any of this work, but the story behind why the survey even occurred (which I’m relaying secondhand) is perhaps the most interesting part.
If you recall, there was an ACR Taskforce on Certification in Radiology that was initially authorized in 2019 and concluded in 2020. You can read my highlights and analysis of their work here.
You also might not recall said task force, because their work apparently marks the only time in history that the ACR Board of Chancellors voted against authorizing a task force to submit their findings as a paper to the JACR. What could have been a paper shared with the broader radiology community was instead buried in a lonely random corner of the ACR website.
This is politics at work, of course.
Behind the scenes, the executive committee asked the task force to water down their language and conclusions, remove certain points, and generally “be nice.” The ACR, trying to repair some historically sour relationships with other radiology societies, didn’t want to be mean to the ABR. It probably doesn’t help when inbred leadership positions across multiple societies read like a game of musical chairs. It was apparently after multiple rounds of softening edits that the task force report was eventually buried anyway.
As a consolation, the board did permit a next-step survey in order to ascertain the true feelings of the radiology community (and not just the task force’s presumably squeaky wheels). The ACR used an outside consultant to help generate a fair survey, and then at the subsequent request of leadership, all “irrelevant” questions concerning the ongoing lawsuit, handling of COVID-19/testing delays, and the kerfuffle over the MOC agreement, etc were excised.
The survey results paper was initially submitted to JACR in 2021 and was—as you may have surmised—also rejected (though please note that the JACR is editorially independent). Much back and forth ensued—largely in order to limit perceived “bias against the ABR”—and the paper you see was finally published a year later.
In the end, thanks to editorial assistance, the limitations section is longer than the neutered discussion.