It’s often said that large organizations are difficult to steer and slow to change course, but that’s only part of why they sometimes act in seemingly inexplicable ways. There’s another more insidious reason, and that is conflicts of interest, not just within leadership but also in the changing demographics of the membership.

A passage from “Value Chain: Where Radiologists Should Put Their Focus in Threats Against Income” by Seth Hardy MD MBA in Applied Radiology:

So, while private/public equity firms can use leverage to amplify profits to the upside, leverage has an opposite effect when gross income is in decline. Any cuts to reimbursement would be truly devastating to these firms’ employees; since the debt holders get paid before the radiologists, the impact on employed radiologists’ salaries may be significant. As equity-employed radiologists make up a greater share of dues-paying members within organized medical societies, it is easy to understand why the proposed CMS cuts were characterized as draconian by those societies. But a clear understanding of value chain by physicians is increasingly critical to evaluate the rhetoric of our medical society leadership.

I am now a partner in a physician-owned independent radiology practice. A CMS paycut would mean that we earn commensurately less money—not that we will become insolvent.

That should count for something when choosing where to work.

A passage about limited resources and optimizing imaging from The Emergency Mind: Wiring Your Brain for Performance Under Pressure by Dan Dworkis MD PhD:

Within the broader context of your responsibility however, there frequently will be significant variability in the relative urgencies of individuals being imaged. Some patients—like a person seemingly experiencing an acute stroke—do need to be scanned immediately. Others—such as a patient with abdominal pain, stable vitals, and a reassuring physical exam—while no less “deserving” of those resources, would receive nearly equal benefit from being scanned now as in an hour from now. Optimizing care across the field in this context would involve prioritizing CT scans for those patients who would receive outsized benefits from immediate imaging, even if this makes some other patients wait longer.

Put a different way: If everything is stat, nothing is stat.

Stat abuse is one of those crimes especially tempting to inpatient teams in busy hospitals. It’s natural to want answers (and dispo) as soon as possible, and we assume that we will get them faster if we increase the priority of the exam.

All a clinician knows is that sometimes something ordered routine takes forever and that ordering stat should generally result in it being performed faster. They may not even care if the read is prioritized in all cases so long as the patient is freed from the waiting and future transport.

It’s also human nature for there to be a distribution with certain individuals ordering an outsize proportion of “stat” exams. The negatives of over-ordering or inappropriate priority are almost always placed on other staff. In a zero-sum game, selfish behavior may be an optimal choice for individual success even if it makes the system less efficient overall. Hospitals very rarely scold their staff for such abuses.

I don’t think most clinicians even have any idea where along the spectrum their behavior falls. Knowledge of outlier performance one hopes might curb excesses, and that data would certainly be helpful for individuals to know (presuming those individuals are capable of feeling shame and said shame functions as a deterrent). Such information would have to be long-term and stratified well to be meaningful (we should expect different levels of stat exams as a fraction of orders from different hospital units, for example). Otherwise, data are dismissible.

Ultimately, pleading and punishment are often ineffective and/or undesirable.

A more helpful approach would include data to guide decision-making on a case by case basis:

The EMR should show in real-time the expected wait for different study types based on the current queue and exam types pending, both inpatient and outpatient (i.e. how many unnecessary exams are obtained during an inpatient stay due to fears of long delays for outpatient follow-up?). Yes, a routine study may unexpectedly get bumped further down the line, but a smart system would incorporate predictions based on the current patient census, admission diagnoses, time of year, and whatever else some machine learning algorithm would include its impenetrable black box of Skynet code.

It would be extremely helpful for all parties to know if an MRI should be expected today or tomorrow, sometime this afternoon or more likely at 3 am.

And so, yes, of course, people are working on this in the machine learning world. But hurry up. I for one will continue to welcome our AI overlords and their promised efficiency gains, but I’m still waiting.

From Suneel (brother of Sanjay) Gupta’s Backable: The Surprising Truth Behind What Makes People Take a Chance on You:

Apply the following quotation to why doctors don’t want to make the call:

If the fear of betting on the wrong idea is twice as powerful as the pleasure of betting on the right idea, then we can’t neutralize the fear of losing with the pleasure of winning. We can only neutralize the fear of losing with…the fear of losing. Enter FOMO, the fear of missing out. For backers, the only thing equally powerful to missing is…missing out.

Gupta goes on to discuss how potential backers initially too scared to be the first investor eventually pile on to avoid missing out on rare unicorns.

The fear of betting on the wrong idea in medicine manifests through overtesting and hedging. More than our desire to be right, we really don’t want to be wrong. But we can’t use the usual FOMO to our advantage, because medicine isn’t about making pitches or raising money but about directly helping individual people.

We don’t want to miss anything and so are forced to entertain everything, even if that means everyone in the ED gets a CT scan or a radiologist gives an impression a mile long with the words “cannot be excluded” featured prominently next to something extremely scary.

The true solution is this: we need to disentangle the outcome from the process. You can have good outcomes from bad decisions (dumb luck) or you can have bad outcomes after good decisions (bad luck). Luck and uncertainty are part of life, and they’re a big part of medicine. We should expect some bad outcomes even when doing the right thing, and we shouldn’t forget that overtesting and overdiagnosis have their own costs, risks, and harms. Passing the buck to the future doesn’t mean it won’t be paid.

By not making the call, we are making a decision: a decision to abdicate the diagnostic yield of an encounter or examination.

There are absolutely times when uncertainly is prudent. There are true “differential” cases. But the FOMO of diagnostic medicine should be passing up an opportunity to clearly define the next steps in a patient’s care.

Last year, the ABMS—the umbrella consortium of medical specialties—waded into the established toxic mess of medical training schedules with a new mandate to provide trainees with a nonpunitive way to be parents, caretakers, or just sick:

Starting in July 2021, all ABMS Member Boards with training programs of two or more years duration will allow for a minimum of six weeks away once during training for purposes of parental, caregiver, and medical leave, without exhausting time allowed for vacation or sick leave and without requiring an extension in training. Member Boards must communicate when a leave of absence will require an official extension to help mitigate the negative impact on a physician’s career trajectory that a training extension may have, such as delaying a fellowship or moving into a full, salaried position.

6 weeks over the course of an entire residency may not seem like much given the vagaries of life, but it’s a better floor than many programs currently offer. A graduation delay sucks, and it’s the kind of punishment for living your life that causes many doctors to put off big milestones like starting a family. Medical training already takes a long time, and ~1 in 4 female physicians struggle with infertility (and in that study, 17% of those struggling would have picked a different specialty).

This issue is being addressed across medicine, but we’re going to discuss it in the context of radiology because I am a radiologist.

The American Board of Radiology’s recent attempt at how such language should look has drawn some ire on Twitter. Here is their email to program directors that’s been making the rounds:

They proposed that a program “may” grant up to 6 weeks of leave over the course of residency for parental/caregiver/medical leave as a maximum without needing to extend residency at the tail end. The language here doesn’t even meet the ABMS mandate, which again states that a program “will” provide a “minimum” of 6 weeks (and explicitly states that said 6 weeks of leave shouldn’t be counted against regular sick time).

The ABR could have simply taken the straightforward approach of parroting the ABMS mandate. They could have—even better—taken the higher ground with an effort to trailblaze the first generous specialty-wide parental leave policy in modern medicine.

Instead, they have advocated for a maximum of six weeks, because any more and they feel they wouldn’t be able to “support the current length of required training.” As in, if a mom gets 3 months off to care for a newborn then the whole system falls apart.

I think they realized it would be prudent to ask for feedback first and then make the plan because a new softer blog post removes any specific language:

We need your input to develop a policy that appropriately balances the need for personal time including vacation as well as parental, caregiver, and/or medical leave with the need for adequate training. 

It is important to realize that the ABR is not restricting the amount of time an institution might choose to allow for parental, caregiver, and/or medical leave, nor are we limiting the amount of vacation a residency program might choose to provide. These are local decisions and the ABR does not presume to make these determinations. However, above a certain limit (not yet determined), an extension of training might be needed to satisfy the requirement for completion of the residency. 

Of course, in the original proposal, the ABR literally did want to limit program vacation (to 4 weeks, see above).

After the mishandling of the “ABR agreement” debacle and the initial we-can’t-do-remote-testing Covid pseudo-plan and now this, I hope the ABR will eventually come to the conclusion that stakeholders matter and that we can make radiology better by working together as a community.

Radiology is a “male-dominated” field, but it shouldn’t be. A public relations win here could make all the difference.

Plenty of Slack

I think there are more than six weeks of slack in our 4-year training paradigm, and it’s hard to argue otherwise.

When the ABR created the Core Exam and placed it at the of the PGY4/R3 year, they created a system where a successful radiology resident has proven (caveat: to the ABR) that they are competent to practice radiology before their senior year. It created a system where the fourth year of residency was opened up largely to a choose-you-own-adventure style of highly variable impact.

We have ESIR residents who spend most of their fourth-year doing IR, and we have accelerated nuclear medicine pathway residents that do a nuclear medicine fellowship integrated into their residency. There are folks early specializing into two-year neuroradiology fellowships during senior year, and others who take a bevy of random electives that they may never use again in clinical practice.1(I did 3-month nuclear medicine and MSK mini fellowships during mine. And an extra month of cardiac imaging. Guess how mission-critical all of that ended up being for my career as a neuroradiologist.)

We have many programs with a whole host of extracurricular “tracks” where residents might spend protected time every week doing research, quality improvement, or clinician-educator activities. I would know, I did all three during my residency. We have residents doing research electives and all kinds of other interesting things that may worthwhile but have no positive impact on their ability to practice radiology clinically, which is the primary purpose of residency training.

A hypothetical example: Take a research track resident with one half-day protected time every week for 40 weeks a year (say because of 8 weeks of night float and 4 weeks of vacation). That’s 20 days a year of reduced clinical activity. 20 working days is basically a month. If they have their R1 year to just focus on learning radiology before taking call, then over the next three years that resident would be “missing” 3 months of clinical time. But no one is seriously arguing that these tracks should postpone residency graduation.

We already have a system where there are minimum case requirements for residents to complete residency training. Last I checked, the ABR is certifying radiologists in the domain of clinical radiology, not their number of peer-reviewed publications or ability to do a sick root cause analysis.

Radiology residency may be four years after a clinical internship, but it’s clear that there is no standard radiology training program clinical “length” despite that fixed duration. Some residents are already doing far fewer months.

No one is adding up diagnostic work hours and saying you need 48 weeks/yr * 52 hours/wk * 4 years = 9,984 hours.

It’s not a thing, and it shouldn’t be.

Competency-based Assessment and Reasonable Limits

The core problem is that we have time-based residencies masquerading as a proxy for competency. You don’t magically become competent when you graduate. Competency is a continuum. Hiring trainees for a set number of years is convenient. It’s easy to schedule. It’s easy to budget. But it’s an artifact of convenience, not a mission-critical component of clinical growth.

There are R3 residents who are ready for the big leagues, and there are practicing doctors who should honestly move back down to the minors. No one is going to argue that a little more training makes you worse. But the logic that more is better gets us to the unsustainable current state of affairs, where doctors are accumulating more and more training to become hyper-specialized in the least efficient way possible while non-physician providers bypass our residency/fellowship paradigm to do similar jobs with zero training.

We all get better with deliberate practice. The question isn’t: is more better? The question is how much less is still enough for independent practice?

Obviously, the ABMS member boards like the ABR don’t exactly have the power to force institutions to change policies directly, and they probably don’t want to. But they do set the stage by mandating the criteria for board eligibility.

I would argue that the ABR should set a minimum threshold and no maximum. If a program is happy with that resident’s progress and they pass the Core Exam, then consider the boxes checked. Let everyone be treated with dignity and then give the programs the flexibility to compete in the marketplace of support.

When my son was born, I was able to take 4 days of sick time and then went straight into night float. That’s bullshit. You want to see motivation? Tell an expecting resident that if they’re a total champion that they can spend as much time as they need with their baby without delaying graduation.

Less than 6 weeks is unacceptable. And while a 6-week minimum is an improvement, I think the true minimum consistent with current training practices that should also have a chance of being implemented is three months.

I’d love to see six months or more. I don’t think that’s going to happen as a minimum, and there’s a very reasonable argument against it as underperforming residents really may need some of that time back. It would be nice to see language that demands 3 months, has no maximum, and strongly encourages programs to work with residents on a case-by-case basis to ensure they are ready for graduation with however much time they have.

But the first step is to have a minimum that doesn’t punish women who want to stay home with their infants until they’re done cluster feeding. Convince me otherwise.

Fairness

The ABR doesn’t use the language of “fairness” in their email, but I suspect the perception of fairness is at play. It’s almost always at play when older doctors consider policies that might benefit younger physicians. It’s the I-did-it-this-way-and-I’m-amazing-so-it-must-be-an-integral-part-of-the process. It’s the hazing.

Right now, some lucky residents across the country get varying degrees of time “off” thanks to PD support in the form of research electives, reading electives, and program staff simply looking the other way. We need to standardize a fair minimum that enables programs to provide a consistent humane process and not just put trainees solely at the mercy of their PDs and local GME office.

Yes, it’s true that if you allow parents time to be parents or people to take care of loved ones or people time to recover from illness that some residents will work fewer months than others. Every resident has their unique experience, but a policy change will also mean that every resident may not have a similar “paper” experience. That’s a fact.

Some people will say, that’s not fair. That it’s not fair to single residents or non-parents. That it’s not fair to the able-bodied. Or to those whose aging parents are healthy or have the resources to support themselves.

But let me provide a counterpoint:

I don’t think fairness means that every single resident has to have the exact same experience. They already don’t. I think fairness means we treat humans with the respect and compassion that every person deserves. I want to live in a world where everyone gets time to be a parent, even if yes, that world means that some doctors may have a career that is a few months shorter.

I think fairness means not punishing people when life happens just because making people jump through hoops makes it easier to check a box.

If you’re ready to practice, you’re ready.

If we need to reassess the validity of an exclusively time-based (instead of competency-based) training paradigm in order to do that, then let’s get to it.

The ABR is accepting feedback until April 15.