The ABR and Platinum Transparency

It’s the time of year for breaking New Year’s resolutions and paying annual fees to the ABR.

In honor of the season, from the American Board of Radiology’s blog:

“In October, we posted on our website the most recent financial statements for the ABR and the ABR Foundation. Postings include the 2020 990 forms and statements of financial standing for the year ending December 31, 2020.

Additionally, since 2017, the ABR has earned GuideStar’s Platinum status, the highest level of organizational transparency recognition.”

I can appreciate the desire to toot your own horn but perhaps less so the justification for self-congratulation.

The ABR, like all nonprofits, must furnish their Form 990 every year. The additional financial statements they recently posted online essentially contain the highlights from this mandatory filing. They are the same documents I’ve also personally obtained in the past in response to a request for greater financial transparency/information. They are overall less detailed and differ only in some minor categorical changes due to their nature as documents intended for internal review and not regulatory compliance.

Now, this is of course outside my wheelhouse—I’m not a compliance officer at a nonprofit nor a federal auditor—but essentially doing the minimum is—to me—not a cause for celebration or even the sweet semi-embrace of patting your own back. I don’t expect a high five for not stealing nor a gold star for filing my taxes on time every year. Those are the rules. And if that small effort places the ABR in rarefied company amongst nonprofits, that probably says more about the United States’ implementation of the nonprofit tax designation than it does about the ABR.

In case you were curious, the ABR said it lost $4.2 million dollars in 2020 from their…strategic reserve of $46+ million. The ABR’s functional expenses have typically ranged from $13-15 million during the recent period from 2012-2017 and up to $17.2 million in 2018. 2020? $24 million.

The two biggest expenses in 2020 according to the financial statements were $11.2 mil for “office expenses” and $9.8 mil for “personnel expenses.” Some of the financial statement numbers differ slightly from the Form 990 for reasons I wouldn’t pretend to understand, but the official document breaks down that office expense a bit further and attributes $8.7 mil of it to “occupancy” (according to the IRS that’s “rent; heat, light, power, and other utilities expenses; property insurance; real estate taxes; mortgage interest; and similar occupancy-related expenses”).

That occupancy figure is a big jump. Here’s what it’s been in recent years:

2019 $1,371,602.
2018 $932,561.
2017 $1,092,930
2016 $383,165
2015 $395,661
2014 $1,147,284

I sent the ABR a congratulatory email about their Guidestar Platinum status and asked if they could provide some more information about this portion of their functional expenses and in particular the significant jump during the pandemic. To his credit, Executive Director Wagner personally responded:

The amount in question includes costs related to our commitment to a fully remote testing model during 2020. Some of the specifics of these transactions are bound by standard non-disclosure terms with outside firms.

I know you’re thinking that $7+ million in additional occupancy expenses for a testing process that involves less, umm, occupancy is a bit counterintuitive. Unfortunately no details were forthcoming, but one potential large expense could have been a commercial lease buyout for the now-defunct large exam center in Chicago (the ABR owns its office building in Tuscon).

In related news, I had also inquired about that lease, and he was gracious enough to provide a very specific answer:

As of January 31, 2022, the ABR will have no active lease agreements, so our occupancy costs will be significantly lower moving forward.

The lease is up mere days from now. Therefore, in this new world of platinum transparency and financial stewardship, candidates and diplomates should almost certainly expect a significant decrease in fees next year.

(Right?)

The Private Equity Model in Medicine is Flawed

It can be hard for trainees in the job market to make sense of the current state of affairs. Everyone knows private equity companies have been gobbling up practices around the country in an ever-consolidating market, but the implications of this trend are another matter entirely.

Most people willing to talk openly about private equity and radiology, for example, are those not working for private equity in radiology. The messaging from those in the industry is usually a vague hey come on over guys the water is fine. And there are several reasons for this. One big one is that many of these deals are fresh, and the partners who’ve sold their practices to private equity are still in the vesting period for their buyout and contractually obligated to continue working and not undermining the groups they’ve sold. There are nondisclosure agreements in play, and folks are not gonna be posting about how terrible a decision it was on Facebook while simultaneously recruiting to keep the practice afloat amidst an exodus of associates. Even unhappy associates are unlikely to badmouth their group publicly, certainly while employed but often even after leaving due to bad karma/small world effects.

However, discussion in private tells a different story.

One of the perks of writing online (and working for a large, democratic, independent, 100%-radiologist-owned practice) is that I get to talk to a lot of people.

And for residents, fellows, and those wondering how things are going, here’s my impression: the private equity model in medicine is fundamentally flawed.

(I should clarify before we go on that private equity is a financing model and not an operational certainty, though PE-firms do have a well-deserved reputation for corporate-bad-acting in the name of short-term profits even when doing so damages the underlying business’ long-term prospects).

((I should also mention the opposite isn’t necessarily true either: just because a practice is independent doesn’t mean that it is therefore honest, well-run, or democratic. Every potential job should be evaluated on its own merits)).

(((And lastly, plenty of other practices, including academic ones, have been using the same techniques to increase revenues at the expense of the academic and patient care missions. If growth and profit are the primary metrics for a healthcare enterprise, then high-quality care and intangibles like good teaching will invariably suffer.)))

The Pitch

The only doctors who can reliably benefit in a private equity transaction are those senior partners close to retirement who can take their money and retire. They often do this by destabilizing that group for the long term and undermining the profession.

There are good reasons some doctors might make less money in the future, such as in order to increase access and improve health equity or to spread the zero-sum Medicare pie more evenly between different specialties.

However, sacrificing autonomy and paying a large fraction of revenues to a corporate overlord is less likely to be one of the good ones.

I want to be clear that not all groups that have sold to PE have done so in an opportunistic fashion just to cash out, there are many lines the PE folks use to entice groups to sell.

For example, they may argue that they will be able to make up for their cut by negotiating higher rates under a bigger corporate umbrella with a larger market share. (While theoretically possible, this is usually not the case. Reimbursement rates are generally falling, and negotiated rates rarely go up sufficiently if at all to make that math work out. In particular, the No Surpises Act, if current challenges fail, will cause substantial downward reimbursement pressure).

They also will argue that they can leverage IT infrastructure, “AI,” and other goodies to make your practice more efficient. (But ultimately the increased efficiency is mostly related to radiologists simply reading more cases per day. That’s the kind of efficiency that corporate America is used to. Squeezing more.)

Other times they may use market dominance to aggressively compete for contracts and force groups to assimilate (i.e. the Borg method). This is especially true for second-order acquisitions in a metro after a private equity firm has already captured significant market share, allowing the firm to mop up more groups and hopefully achieve local dominance. Even in areas without a substantial PE presence, firms can sometimes use their relationships with health networks or imaging center chains to exert a lot of pressure, particularly when contracts are up for renegotiation. The general trend of healthcare consolidation has made this easier.

The Sale

So what happens in a private equity sale? Recently, that has meant that a group has sold a controlling share of itself to the private company in exchange for a monetary sum that typically vests over a period of time (e.g. five years). A significant portion of that money (e.g. 20-50%) isn’t cash but is instead “equity” (an ownership stake in the form of stock) in the parent company. That equity is always a minority stake and never results in control. The “shares” a physician holds are a different class than the “shares” the PE-owners hold, and that makes all the difference.

The partners who get the benefit are also on the hook for the vesting period. If you don’t stay, you don’t get all the money. They also have a contractual obligation to keep the group running and reproduce the financials that gave rise to the sale. And this is important because keeping the group running is not always an easy feat, especially if the partners were already pumping the rank-and-file for higher productivity in order to look better before selling.

After a sale, the PE owners eat first. The initial buyout amount is typically a multiple of a capitalized share of group revenue. The bigger the fraction sold, the larger the number (e.g. 30%) the new PE owners take from operating revenues (and therefore the less available to the doctors actually doing the work). If the partners were aggressive in maximizing the buyout windfall, the less they’ll earn going forward in salary.

The Profits

In the world of operations management, a company can increase its profits by increasing revenues and/or decreasing costs. When you take over a new business, increasing revenues may be a goal, but it’s not a guarantee and rarely something you can achieve out the gate in an otherwise reasonably functioning enterprise. Lowering costs though? Well, that’s some easy math.

The low-hanging fruit is to “streamline” operations and increase efficiency, which in radiology mostly amounts to each radiologist reading more RVUs, hopefully also for less pay. You could lose/fire some people and keep patient volumes the same, or have the same number of people do an increasing amount of work instead of hiring to handle growth. When non-partner rads quit and you can’t recruit, then you automatically earn higher profits as the same amount of work is divided among the remaining rads on staff. Congrats.

Decreased pay and increased work are the hallmarks of value extraction in the corporatization playbook (and certainly not unique to the PE-financing model).

But, ultimately, this is where the math breaks down.

This is not a silicon valley start-up where you hope to hit a home run with crazy multiples or a unicorn IPO. These are mature service businesses in a highly regulated industry. There’s simply isn’t enough operational wiggle room for a company to take a big revenue percentage off the top without changing the function or structure of the underlying business in undesirable ways. There are no exponential profits like through selling software. Doctors earn money linearly through patient care. You earn more money by doing more work. There is no free lunch.

I have yet to see or hear of an example where true efficiency gains have offset the haircut or where billing improvements have led to substantially better collections (radiology practices, in general, have not been the dominant perpetrators of unsavory practices like surprise billing). There may be examples out there, but if there are, those positive details are being kept under even better wraps than the negative ones that have managed to filter through.

No one goes into medicine because they want to practice dangerously high-volume care.

The Death Spiral

Value extraction is not the same thing as wealth creation. A good business doesn’t just take a slice of the pie, they make the pie bigger. Practices can grow organically, but it is no easy feat for a mature practice to grow at the level required to please equity investors. And investors must get their returns.

Right now there are more job postings on the ACR job board than there are graduating trainees. There is quite literally a shortage of radiologists, and many new graduates are shying away from PE practices when they can. In order to compete, PE firms have begun increasing pay and shortening “partnership” tracks in order to stay competitive, but ultimately these moves will only further erode the profits they need to make to keep the enterprise rolling and pay down their debts.

I’ve been doing some recruiting for our practice recently and in doing so talked to multiple people from all across the country who are trying to bail from private equity managed practices. The stories are different and yet all the same.

Partners who regret that sale, who often felt forced to sell due to local factors when other groups had already sold or who bought the line that they needed to get big to survive.

Groups that were promised that under the new umbrella, reimbursements would rise and that it was those higher revenues and magical unicorn fairy dust efficiency gains that would pay for the rent-seeking of their corporate overlords and leave their groups healthy for the future.

Groups that then didn’t see those promises come to fruition but did have an obligation to keep their groups afloat during the vesting period even after working conditions worsened and young radiologists left, creating a death spiral where the job gets worse and worse leading to more call and higher productivity demands and–of course–more difficulty recruiting. This perpetuates until either the group can’t fulfill their contracts and they lose the business or, as will be happening increasingly soon, the partners flee for retirement or other greener pasture independent groups for the next stage of their careers.

The Future

(/ what is a young doctor to do?)

You should do whatever you want.

But since you’re here, here’s what I would do: If you are a young grad and want to lay the foundation for a long-term career, I would suggest avoiding these practices when possible. At the minimum, you must find out about turnover, find out why people left, and ideally talk to those people for an honest assessment. These are things you should be doing for any potential job but are especially important in the recent acquisition setting.

Even terrible jobs don’t sound terrible when they’re being sold.

The model is flawed, and things are going to get worse in these practices before they get better. As of right now, there are certainly PE jobs out there that are day-to-day solid, and they might stay that way. But recent history has shown that we shouldn’t take the future for granted.

Of note, the PE funding model allows these companies to do things, at least in the short term, that lead to growth or at least a good-on-paper job. They can and do use debt (borrowed money) to grow the business: to buy more practices, invest in infrastructure, etc. Many of these well-paying desirable-seeming positions are not funded by operations but by debt, meaning that the company has borrowed money to artificially pay well for jobs that would otherwise be unaffordable based on the revenues of the business itself. This may not be sustainable.

That sort of leverage is how companies scale rapidly. Recently, we have come to the point in the cycle where debt is being used to prop up struggling service lines. Soon, we may get to the point where cash flows can’t cover existing loan obligations and more debt is needed to pay off the old debt (i.e. The Ponzi stage).

For example, desperate to hire mammographers, PE practices have been offering generous employee track positions. These are probably both temporary and unsustainable. As a young rad, you might make a lot more money in the short-term immediate future taking one of these jobs, but the deal will stay just as long as it needs to for recruitment and not a moment longer. A reimbursement change to digital breast tomosynthesis a few years from now or a slash in technical mammo reimbursement probably won’t change your salary much in a democratic group, but it likely will if you’re picking a job based on chasing the biggest number you can find.

While finishing up training, you also may have no idea what it feels like to earn that extra high salary either. If you don’t mind jumping ship in a year or two for healthier volumes or a real say in the direction of the practice, then you can take that risk. But if you’re hoping to establish roots somewhere, then some extra money upfront may not be the right call for you, especially when you consider the non-competes these practices universally utilize (the biggest existential threat to a corporate practice is its doctors quitting and reforming a new practice under their noses).

It’s not that one choice or the other is wrong; it’s that you need to have your eyes open, understand the situation, and make the right choice for yourself.

Again, there’s no free lunch. Many independent democratic groups simply can’t sweeten the pot for individual hires the way a group hiring employees can. When you own your practice, the company’s profits are your profits. When you’re an employee, your pay is the biggest cost for the company, and physician salaries are the biggest expense for any corporate-style practice (academics included). The goal is to pay you the least amount possible that the job market will tolerate. Right now, the job market is hot and pay is pretty good. But markets change.

In addition to the obvious operational problems of the death spiral, buying growth hasn’t been cheap.

For example, the credit agency Moody’s recently said that the country’s largest radiology practice, Radiology Partners, has a debt load of around $3.2 billion due between 2024-2028: “The practice’s liabilities over the summer remained at roughly 8 times its earnings before interest, taxes, depreciation, and amortization.”

That’s a lot of leverage and a significant “execution risk” as Moody’s points out. It may not be possible for a company like RP to service this debt on earnings alone, and it may well need to raise more money to pay off its previous funding.

You see where this is going.

These companies will need more money than ever at the same time that their underlying businesses may become more unstable than ever. The big reason some lucrative specialties are in this situation is that it’s been so easy to raise capital and so easy to take on debt, two things that may not last forever. If the credit markets tighten, it may not be possible for companies to borrow said money when they need it. If earnings are flat or falling thanks to regulatory and reimbursement changes, no one may be interested in pouring good money after the bad.

The fact: no one knows what’s going to happen in the next decade.

While the easiest profit for a PE firm is to replace higher partner salaries with lower associate ones, that still requires that you are able to find enough people willing to work for lower salaries. Instead, with the current job market, they’ve often been forced to offer higher salaries. Higher salaries mean fewer profits unless the job really sucks. 

What you’re left with is a job that might have the right numbers on paper but at great risk for a lot of empty promises on the ground.

Ultimately, these are trends, not destinies. Not every PE-backed group is bad to work for and certainly not every independent group is good. And I definitely can’t fault any young rads for taking temporarily good jobs that might not work out long-term when their older colleagues are the ones that helped create this mess in the first place.

What I can say is that–philosophically–I don’t think accountability to non-physician third-parties can lead to sustainable high-quality patient care, and the majority of young radiologists agree. If you feel compelled to take a job due to local factors, then so be it: just know what you’re getting into, and be prepared for the job to change–potentially substantially–over the next few years.

Healthcare is very complicated, and it’s no longer as isolated an industry from general economic trends and market forces as it used to be. The storms are harder to predict and more challenging to weather. Every middle man is an extra layer of complexity, and that complexity should add commensurate value to be justified. I have yet to see a convincing argument that this is the case.

The Takeaway

All of this is not to say that as an individual you can’t have a good experience working for a particular group regardless of their financing or operational structure (even if the underlying business model is flawed).

And, there can be real perks to being an employee or contractor.

This is likewise not to say that you can’t be taken advantage of and treated poorly by an independent group. This absolutely does happen, and I want to be clear that physician ownership is unfortunately not synonymous with healthy group culture.

This is merely to say that the need to provide profits to a third party for whom profit is their modus operandi introduces unavoidable friction to running a healthcare business that appropriately balances high-quality patient care, physician reimbursement, and a sustainable work model.

And the next few years should be interesting.

All About the Neuroradiology CAQ

The CAQ exams are likely the least discussed and widely known facet of radiology certification. Until now.

Background

The CAQ–or, Certificate of Added Qualification–is something most radiology residents and other doctors don’t even know about. It’s an extra subspecialty certification you get by giving the American Board of Radiology (ABR) a bunch of money and taking an extra subspecialty exam so that you can say you did it. Some radiologists then put their CAQ-holding status at the bottom of their reports (“This study was interpreted by a CAQ Neuroradiologist” or equivalent) under the pretense that the CAQ confers authority and quality to their work (as opposed to those things coming from actually being thoughtful and good). You see, many radiology fellowships are actually not accredited by the ACGME, and most subspecialized radiologists have no magical exam they can take for true bragging rights. You can do an MSK fellowship, and you can say you are a fellowship-trained subspecialized musculoskeletal radiologist–but you don’t have a CAQ as a proxy for “subspecialty expertise.”

Historically, CAQs have only been available for neuroradiology, pediatrics, IR (which now has its own boards/residency), and nuclear medicine (which also has a separate board, the ABNM). In practice, neuroradiology is the most popular CAQ. In 2019, 198 examinees sat for it. Compare that with 59 for pediatrics. Nuclear medicine? 4.

Many practicing neuroradiologists have never taken the CAQ exam and do not hold the certificate. Some jobs (especially in academics) demand it. It’s also important as an extra credential for expert witness work (if that’s something you’re interested in). Many clinicians may want a subspecialized neuroradiologist, but the majority have no idea the CAQ itself exists.

For years, the CAQ was another exam you had to fly across the country for. This was especially galling in recent years because it’s just a half-day exam, and–with the advent of the choose your own adventure style of the Certifying Exam–largely an expensive and duplicative waste of time.

Registration & Fees

To officially learn more about the CAQ, see the ABR’s handy page titled neuroradiology.

In order to register, you generally must have completed a 1-year ACGME-accredited fellowship and been in practice for one year (or completed a second year of fellowship) with at least one-third of your time dedicated to neuroradiology. So yes, you can still practice as a general radiologist and sit for the CAQ.

When you register, you will need to provide–in addition to a sack of cash–a diploma from your fellowship and a letter from your service chief or department chair acknowledging that you’ve been in practice long enough and have been doing enough neuroradiology.

Registration is open only from February 1 through April 30. This is because confirming your eligibility is an apparently arduous task and cannot be stomached year-round.

I actually meant to register in 2019 but missed the window. When I tried to see if I could still take it anyway, I was told via email: “The time span from the close of the application window is required to process and approve/decline applications based on training – for which the process is thorough and time intensive.”

What is this process? They check your diploma and letter. Ironically, despite the form being very short and this process being both thorough and time-intensive, they didn’t notice my letter (you do get a copy of your application emailed to you, and it was sitting right there), so I had to re-send it. The ABR person acknowledged it momentarily, and I was then magically approved to send in more money.

In 2020, the fees were $1635 to apply and another $1635 to register for a total of $3,270.

As of September 2021, the exam fees have dropped.

You now spend $640 as an application fee and then later a separate $1280 exam fee for a total of $1,920. You’ll spend another $640 if you fail and need to take it again.

Format

The testing format and software are identical to the ABR’s other computer-based offerings like the Core and Certifying exams with an image-rich gauntlet made up of predominately “single best answer” format (and typically “what is the diagnosis?” style) questions.

The exam is composed of 180 questions in equal parts from the categories of Brain, Spine, and Head & Neck. Unlike the current iteration of the Core Exam, you can condition an individual section and be forced to re-take just that section (at least you won’t have to travel for an hour-long experience). If you condition two sections, you simply fail the test.

You have 3 hours 15 minutes allotted for the questions, 20 minutes of break time, and 20 minutes for the tutorial for a total maximum experience of 4 hours 5 minutes.

Between 2013-2019, between 158-232 examinees have taken the exam annually with a passing rate between 79-95% (mean 86%) and a condition rate between 4-12%.

My Experience & Results

On exam day, I got a brief connection lost warning twice, lasting for a few seconds before being reestablished, otherwise no interruptions. For more discussion of the ABR’s online platform, please see this post: The ABR Online Testing Experience.

Despite the fact that many review resources like to show you multiple questions based on a single image (and the official guide discussing it as I describe in the next section), the vast majority of questions are “What is the diagnosis?” questions. This can lead to some frustration, as in real life, many things (e.g. many spinal tumors) are straight differential cases that you would never come down hard on, and a couple of blurry MR images from the 80s aren’t how anyone is used to reviewing cases in real life.

The easy parts of the exam are similar to the OLA MOC questions, and the harder parts, are, well, harder. The best preparation strategy is to make sure you can get all the easy questions right, leaving yourself room to guess like everyone else when they show you some blown-up spine or a pediatric case you haven’t seen or thought about since you prepared for the Core Exam.

It took me two hours forty minutes including breaks. With the online format, you can take a break whenever you want, but all previously seen questions will be locked and cannot be altered. You can take more than 20 minutes break but exam time will continue to count down during any additional breaks.

The ABR states results are released in 4-6 weeks. In 2021, it was exactly four weeks to the day.

Like the Certifying Exam but unlike the Core Exam, there is no granular data. You either pass or you don’t.

 

Preparation

As always, the ABR releases a study guide. The current version hasn’t changed since 2017 and is mostly useless: it is a list of all topics in neuroradiology. It does include a few practice questions at the end.

It also seems to be out of date. The guide states that there are 60 individual questions with 180 total items, suggesting that the average case has three questions and that are a lot of second-order questions. Indeed, it states: “The case mix will reflect the typical clinical practice of a neuroradiologist. Thus the majority of the cases will be examples of relatively common entities but the follow-up questions will require a greater depth of knowledge than that expected of a general radiologist.”

This is simply not the case. Like all modern era ABR radiology exams, most questions are standalone diagnosis questions and relatively few are multipart deep dives.

As you might expect, your daily experience as a likely almost entirely adult radiologist does not prepare you very well for peds-type questions or even probably most testable spine pathology, so I encourage you to spend at least a few hours refreshing that material.

Qbanks

A relatively popular but generally not well-reviewed resource is Sulcus, the only neuroradiology-specific question bank. I reviewed it here and think you can skip it.

Board Vitals‘ Certifying Exam Qbank has 179 neuro questions, and 30/82 peds questions are peds neuro (10% off with code BW10). BV has a decent mobile app where you can even download questions for offline viewing and now finally saves your preference for the “show exhibits” toggle in the app, so you only have to hit it once to show the images automatically for all questions. While there is no image manipulation, it’s not necessary in this setting, and you have the choice between untimed vs timed and tutor mode vs test mode.

A practicing neurorad could get through the questions in a few hours, and they are overall easy (you should get most correct without issue), but for the purposes of rapidly getting you in the question-taking mindset, it’s not a bad experience. Then again, you may feel that OLA is enough. Overall, the BV experience is much more pleasant than Sulcus, even though the learning opportunities are lower. It’s definitely a floor, not a ceiling.

There are some negatively framed questions, which I want to say is unacceptable, but the fact is the ABR still hasn’t fully purged them from their tests either. There’s some image reuse for multiple questions, which is a bit lame, as well the habit of asking “which statements about this entity are true” style of question, which isn’t how most ABR questions are formulated these days. Some good high-yield anatomy but giveaway easy for a trained neurorad. I got 90% correct in my warp-speed review; of the ones I missed, I would say 1/2 were straight-up bad questions: a couple were due to bad images (which in fairness the ABR loves to do), and the others had psychometrically bad answer choices on the “which of the following are true” type questions.

Because the peds neuro questions are randomly found within the peds section, I’d recommend doing those on tutor mode so you can just skip the majority. These were super classic diagnoses but may help bring some comfort. I didn’t get any of them wrong but are nice to see since most people don’t do much peds.

Not a great value for the 1-2 days you’d actually use it but cheaper than Sulcus. I think you can probably skip both unless you really want to see more questions.

Case Books

I think good old case books (e.g. RadCases, Case Review Series) are by far the most cost-effective way to prepare.

In my very brief survey, the best collection and value of high-yield low-pain processes and reasonable second-order factoids is Neuroradiology: A Core Review. It includes some high-yield peds and is organized by general theme. The ebook version you unlock with the code inside the cover is essentially a multiple-choice quesiton bank, and each chapter has 34-40 questions grouped into a smaller number of cases (diagnosis question often followed by 1-2 additional fact questions concerning pathogenesis, prognosis, management, etc). A practicing neurorad should probably get almost every diagnosis correct and miss a second-order factoid here and there, which means that it’s probably not a bad resource to use. If you blaze through and know it all, then I think you’re in pretty good shape.

Note that anatomy is not meaningfully covered, so it would still behoove you to make sure you have your gyral and functional anatomy, skull base foramina, cranial nerves, midline sagittal anatomy, head/neck spaces/levels/structures down pat.

While there are a couple of duds, overall the questions demonstrate broad depth, good examples, and some honestly refreshingly well-written explanations. It’s an excellent book. I’m not ashamed to admit I learned some facts that I didn’t know previously or had forgotten, including some fun ones to pimp my residents on and shore up my knowledge of vaguely useful esoterica.

The phone app for the online version is a little buggy, and the images load as thumbnails whether you’re on your phone or just using the full website. You can slam through the book in a dedicated evening at the bare minimum.

If you do more than one case book, you’re going to see a lot of overlap.

Survey Results

I did an informal online survey and got 38 responses. The overall pass rate of the respondents was 86.8%, which is right at the ABR average. Everyone had passed the Core/Certifying exams on their first attempt.

55% had to take the CAQ for their job, and 74% had completed a 1-year fellowship.

How long did people study (and by study I mean an hour or more somewhat consistently)?

  • 5 weeks or more – 15.9%
  • 4 weeks – 39.4%
  • 3 weeks – 18.4%
  • 2 weeks – 10.5%
  • 1 week – 7.9%
  • < 1 week – 7.9%

Of the 5 reported failures, 2 studied for 1 week, 1 for 3 weeks, and 2 for 4 weeks. Not much help there.

I personally studied somewhere around a few hours total looking at Sulcus and BoardVitals during the weeks leading up to the exam and then blazed through A Core Review the night before. So overall less than 1 week, but I think I would have felt better with a full week, maybe two.

I suspect that for most people doing 75%+ neuroradiology–especially if that involves some high-end stuff and not just strokes/hemorrhage/fractures from the ED and degenerative spines from the community–that a week or two is probably fine, but it would seem that over 50% of takers are spending a month or longer with some degree of consistent study.

Only one person who failed remembered and shared their qbank performance: Sulcus: 56%, BoardVitals 76%, and RadPrimer 70%. I’m going to guess you probably want to be at 80%+ on non-Sulcus products, and probably at least 65% if not 70%+ on Sulcus.

I would also guess that if you had borderline performance on the Core Exam, you probably want to put some serious hours in. If you destroyed the Core Exam without a sweat, this will likely be a breeze.

Unfortunately, as with all ABR exams, we simply don’t have the data to meaningfully predict performance.

Conclusion

The CAQ is lame.

It’s expensive, and should absolutely 100% be folded into the Certifying Exam, which can also coincidentally include 180 neuroradiology questions.

There are no particularly good dedicated resources. Sulcus is probably too expensive, too hard, and too demoralizing. While casebooks are generally geared toward the Core Exam, the fact is that they provide a good knowledge floor and will remind you of what should be low-hanging fruit on topics you don’t see often in daily practice.

As with all ABR exams, be prepared to be irritated.

 

 

 

 

The ABR Online Testing Experience

When I finally got around to taking the Neuroradiology CAQ Exam this fall, I finally had the pleasure of partaking in the ABR’s remote testing platform. I put a lot of work into my posts about the Core and Certifying Exams back in the day, but they do hail from the pre-pandemic era.

Here are some thoughts on taking an ABR exam from the comfort of not Chicago or Tucson:

Big Brother

ABR relies on a third-party company called Proctorio for monitoring.

Everything–including the real-time video monitoring, capturing a photo of your picture ID during the start-up process, and the “room scan”–rely on the webcam. This feature was clearly intended to be used on a laptop, which you could easily pick up and spin around the room. The ABR now requires a separate dedicated side-view webcam, which makes the acrobatics a bit more complicated.

Instead of buying a separate webcam, I used a super old DSLR with a $15 HDMI to USB video capture card (the knockoff of the better Cam Link). This works fine (and it’s what I use for Zoom calls to have that beautiful bokeh so that people like me more), but it’s worth noting that if you don’t have good autofocus (and mine is so old that it does not), that it may take a few tries to get the screengrab of your photo ID good enough to satisfy Proctorio’s artificially intelligent needs. Depending on your desk set up, a relatively short cable connecting the camera to the computer or a tripod to have the camera high enough to actually see anything if you don’t have a dresser or something suitable nearby can make the room scan awkward and a bit tenuous. A longer USB cord helps. After around 5 minutes of finagling, eventually, I was allowed to take the test.

You could also use your phone as a webcam by using one of many inexpensive apps like Camo or EpocCam, which is probably the best option, especially if you already have some sort of suitable stand or one of the infinite variety of cheapo phone tripods.

Anyway, what I’m trying to say is I don’t think most people need to buy a dedicated external webcam just for the purpose of taking one of these ABR tests. Especially since most webcams are terrible.

I will say that Proctorio didn’t make me install any apps on my phone, and the Chrome Extension is easy to uninstall. I don’t think anyone is going to have their identity stolen or be harassed by call center employees. While I am admittedly not very experienced with the myriad options for education spyware, it seems like the ABR picked one of the better players.

Computer Set-up

I really wanted to use my home workstation. It has direct fiber internet and a system I use every day for radiology-type stuff. However, Proctorio and the ABR have a 1 monitor rule, and I–in my radiologist glory–have 4 monitors. To satisfy Proctorio, any extra monitors in the space have to be missing from your system entirely, so simply turning them off isn’t good enough. They need to be totally unplugged from your computer so that they don’t show up. I use a dual PC system set-up to read simultaneously for the hospital and our outpatient PACS by swapping monitors and peripherals between two different PCs using a KVM switch. It’s awesome. But the nest of monitor cords is no joke, and the settings are just how I like them, and there was no way I was going spend the time unplugging stuff and jeopardize any of that in order to take a 3-hour exam with a bunch of low-quality JPGs.

Instead, I took it on my 2017 iMac over WiFi, which is across the house from the router, and it was fine. The biggest problem was getting Proctorio happy with the backlighting from the adjacent window overexposing the camera and making me look too dim.

Yes, I did roll over my attending chair, the Herman Miller Embody, from across the house for the experience, and it was worth it.

The Practice Test

The practice test is a 98 question process, but really it’s just designed to get you to make sure you can pass Proctorio’s welcome barriers and familiarize yourself with the software. The content is a random hodgepodge of questions, but there is no performance feedback or answer key, limiting usefulness as an actual practice exam experience.

The content parallels the Core Exam, which is to say I found it more difficult now as a super high-performing experienced attending radiologist than I would have as a resident. Go figure.

The Online Platform

I would show you some screenshots, but, you know, I can’t.

The software is totally fine. It works. You have a bunch of tools to manipulate the images, but since most images are just static screen grabs of middling quality, you usually don’t need to do anything. In fact, the image sizes are small enough and the questions themselves short enough that you really don’t need or even want a large monitor or anything fancy to take the exam. Your average laptop screen has plenty of real estate.

The ABR locks your past performance every 30 questions to prevent you from altering your responses to prior questions after you’ve left the surveillance zone for breaks (aka cheating). Locking so frequently is a touch annoying, and I’m sure the policy frustrates the people who want to blaze through the whole test and then agonize for hours on all the questions they flagged at the end. Psychologically, this is probably healthier, though it does make flagging a question basically useless.

I wish they just locked questions at breaks and not after so short a period, but given intermittent connectivity issues, the shorter batch size probably helps substantially reduce their tech support demands. It’s a worthwhile price to pay for the convenience.

Another irritating feature is that the ABR really wants you to move forward through the exam and not backward to revisit old questions, so much so that if you try to visit the previous question, the software prompts you with a pop-up saying (paraphrasing) “forward is so much better, are you sure you want to go back?”…which is annoying. I think the idea here is that they especially don’t want you to see a question, not answer, go backward, lose access in some way, and then have to unlock the question for you and/or question your integrity. 

On exam day, I got a brief “connection lost” warning twice, lasting for a few seconds before being reestablished automatically, otherwise no interruptions. I know people personally and online who had less good luck, sometimes being completely kicked out and needing to call to have questions unlocked. To their credit, I’ve only heard good things about ABR customer service when it comes to helping with exam connectivity issues.

Overall

Overall these inconveniences are a small price for being able to wear pajamas and take a break literally whenever you want, which is wonderful. The ability to use a bathroom mere feet away or get drinks and snacks on a whim creates a completely different ambiance than a typical testing experience.

Not having to pay for flights and hotels, waste days on both ends for travel, and leave your family is also almost priceless.

In some ways, it’s a little harder to get in the normal high-stakes exam headspace without the suffering, but it’s a breath of fresh air that I enjoyed nonetheless. I bought a twelve-pack of Diet Mountain Dew just for the occasion, and I made myself a nice fresh ice coffee as well (see above, hat tip double-walled insulated glasses) to sip while answering ludicrous questions about differentiating spinal cord tumors. 

If that’s not the dream, I don’t know what is.

 

 

Review: Sulcus Neuroradiology CAQ Prep

The neuroradiology subspecialty exam (aka the CAQ or certificate of added qualification) is a tedious, basically redundant, and expensive waste of time taken by a relatively small number of people every year.

As a result, there are very few dedicated recourses.

In fact, there is only one, and it’s Sulcus.

Based on an informal survey I did of CAQ takers, the Sulcus bank is relatively popular despite what are generally poor reviews online. In my informal poll, almost half of respondents admitted to using it. I chalk this up to the CAQ exam being exceedingly expensive, people not wanting to fail it, and this being the only dedicated product.

Related note: Sulcus also now offers MSK and Mammography programs, neither of which I looked at.

Reviewer Disclosure

Sulcus did not pay for this review nor have they seen it prior to publication.

They did provide me with 7 days of free access. I have a life, so that wasn’t sufficient for me to view the entire product, but it was enough for me to form an opinion. I’m not sure I would have finished it regardless, and I did not purchase the product afterward for further studying.

I also have no discount code for you, dear reader.

Platform

It’s a little clunky, but it works.  

You must “create a quiz” as a separate step before you can actually take said quiz.

There is no tutor mode. 

The site is technically mobile-friendly but the left sidebar (which is just the question numbers) takes priority, meaning that you need to scroll down past the question navigation to do every single question and read every explanation. Very tedious.

Content

There are a total of 562 questions grouped into 175 cases.

As in, there are several questions per case/diagnosis/image(s). For example, doing my first 5 cases used up 16 questions.

The cases themselves are solid. But when each case has three or sometimes four questions, the first is usually high yield, the second is borderline, and the third is basically just for giggles.

The question format is nothing like CAQ. Most CAQ questions are diagnosis-based.

Many Sulcus questions are multiple-choice “pick the correct statement” nonsense, where you evaluate a bunch of statements and then pick the one that is true. It also contains questions that are negatively framed (“which of these are NOT…”) questions that are garbage psychometrically (in their defense, these still crop on ABR’s exams rarely as well).

You’ll also get a lot of extended multiple T/F questions, where you need to evaluate a whole bunch of statements about the diagnosis and get each of them right in order to be “correct” overall. So, the end result–as other reviewers have alluded to–is mostly irritating/demoralizing.

Extended matching questions are pretty rare but fine.

Overall, the bank trends too much toward hyper-detailed in-the-weeds stuff, making it very inefficient to review in quantity for a busy practicing radiologist. The CAQ is an image-based test mostly of diagnosis, so testing a whole bunch of second-order factoids is not worth your time.

In Sulcus’ defense, I have a suspicion that the CAQ exam has changed significantly over the years. It very well may be that its current format more closely resembled the CAQ of old before changes brought the question style more in line with the modern multiple choice offerings of the Core and Certifying Exams. I support this theory with two points.

  1. No one would choose to write questions like this for no reason.
  2. The current (but clearly out of date) CAQ exam study guide from 2017 suggests that most questions would be part of linked question sets: “After the candidate makes her/his choice, one to three follow-up questions will typically be asked.” This is simply not the case. Most questions are solitary single best answer and do not go on to hammer you on miscellaneous second-order details.

Survey Results

I did a brief survey online and got 38 responses. Of the 18 people who said they used Sulcus, there were only two written comments: “didn’t think was relevant” and “was the highest yield by far.”

I think the reality is somewhere in between.

Pricing

$399.

Free Sample

There is one sample case in a slideshow at the bottom of the main page.

Verdict

Eh, pass.

A decent collection of wide-ranging cases; not a bad learning tool but extremely expensive related to other options and not an efficient CAQ review for the practicing neuroradiologist.

Unless you really have a CME fund to burn and nothing else to spend it on, you don’t need something this tedious and demoralizing to get through for the purposes of passing the CAQ exam. Some regular cases books, like Neuroradiology: A Core Review, will get the job done.

If you really just want a chance to see some pretty solid cases, take some great and some excruciating multiple-choice questions, and really hammer some low-yield esoterica to impress trainees and specialists, then this is an excellent choice.