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Put out by Penn....by and MBA.....

Guess that takes Penn off my list of places to apply.
Penn has a real addiction to RRAs. About a year or two ago there was a internet drama about Penn and Yale using these.

Reading the study, it’s a trash experimental methodology. I can’t believe JACR published it, unless the ACR actually wants RRAs to be used.
 
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Penn has a real addiction to RRAs. About a year or two ago there was a internet drama about Penn and Yale using these.

Reading the study, it’s a trash experimental methodology. I can’t believe JACR published it, unless the ACR actually wants RRAs to be used.

Are there any other programs known for doing this? I’d like to avoid the biggest offenders trying to create DR midlevels.
 
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Jesus christ can we not? Are the rad societies going to make a stand against this? I know it may benefit some current rads to be more "productive" but is it actually good for patient care....? Is this going to be a problem? rad extenders and AI now, uff
 
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Probably says more about Penn residents than it does about extenders. Ivory tower residencies with lots of fellows often coddle the residents. Let's see the numbers from a mid-tier program without a bunch of fellows. I bet the difference is gone/minimized.

I feel that the difference between the residents and the extenders stems from the fact that the extenders were trained to do a specific task, presumably by the same attendings who would final sign the studies. The RRAs likely were trained to cater to a specific style, in contrast to residents who learn from multiple different attendings, divisions, and texts. Remember, this study specifically looked at time to final sign and not overall accuracy (which was the same among residents and RRAs).

Differences among residency programs would likely be negligible. If you are training someone to specifically emulate your own style and verbage, you are obviously going to sign off on their report faster versus someone who may say the same thing differently. It seems specious to criticize the residents when the outcome measured does not reflect their accuracy.

For what it's worth, I cannot find the original JACR article. Perhaps they pulled it?
 

Gastrapathy

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To publish a paper with this thesis shows that these “attendings” view residents as their workforce rather than their students. It reflects terribly on the culture at Penn and they should be ashamed. The purpose of a residency is to take a medical student and turn them into an attending. To even make this meaningless comparison shows that they’ve lost sight of that. Sad.
 
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To publish a paper with this thesis shows that these “attendings” view residents as their workforce rather than their students. It reflects terribly on the culture at Penn and they should be ashamed. The purpose of a residency is to take a medical student and turn them into an attending. To even make this meaningless comparison shows that they’ve lost sight of that. Sad.

Seems like First author was a PhD/MBA. Either way, looks like the article was pulled from JACR. Still gonna keep penn off my list.
 

TheDarkness

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Probably says more about Penn residents than it does about extenders. Ivory tower residencies with lots of fellows often coddle the residents. Let's see the numbers from a mid-tier program without a bunch of fellows. I bet the difference is gone/minimized.

I can assure you from having seen hard data that even with extenders, Penn residents are reading far more studies and more complex studies than a "mid-tier program." Why do you think Penn feels like it needs extenders? The volume is colossal. The problem is that Penn is trying to fix the issue in a a controversial manner (intentionally leaving out my personal opinion of the extenders here and the economics behind the decision, so I am not making a value judgment, just stating a fact). Residents there read as much or more on call than attendings at many places, including private practice. P.S. Forgot to mention they still have independent call at Penn, something that is disappearing, even at your vaunted mid-tier programs.

I feel that the difference between the residents and the extenders stems from the fact that the extenders were trained to do a specific task, presumably by the same attendings who would final sign the studies. The RRAs likely were trained to cater to a specific style, in contrast to residents who learn from multiple different attendings, divisions, and texts. Remember, this study specifically looked at time to final sign and not overall accuracy (which was the same among residents and RRAs).

Differences among residency programs would likely be negligible. If you are training someone to specifically emulate your own style and verbage, you are obviously going to sign off on their report faster versus someone who may say the same thing differently. It seems specious to criticize the residents when the outcome measured does not reflect their accuracy.

For what it's worth, I cannot find the original JACR article. Perhaps they pulled it?

I have reason to believe this is also true. When attendings are extremely particular about the language used, even when the resident's language conveys the same information effectively, they will change the report or addend it. An extender working with the same people for a prolonged period will learn their idiosyncrasies.

To publish a paper with this thesis shows that these “attendings” view residents as their workforce rather than their students. It reflects terribly on the culture at Penn and they should be ashamed. The purpose of a residency is to take a medical student and turn them into an attending. To even make this meaningless comparison shows that they’ve lost sight of that. Sad.

This is, unfortunately, the real issue. Assume, for fun, that extenders actually do make radiologists more efficient. Assume that you do not need to be a doctor to read chest radiographs. The comparison to residents, who are in a trainee role, is unnecessary. They could have just shown that extenders make attendings faster and, while controversial, would not have pulled the residents into it.
 
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Penn residents are reading far more studies and more complex studies than a "mid-tier program."

You must have some dog in this fight since you made an account just to comment in this thread. I have heard from multiple people who have first hand knowledge of the program that the residents are treated with kid gloves because of the large number of fellows.
 
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I can assure you from having seen hard data that even with extenders, Penn residents are reading far more studies and more complex studies than a "mid-tier program."

So this is either not true or the same kind of study design comparing radiology residents to X ray techs.

How is it possible you are comparing the complexity of studies to another institution? What is PENNs secret algorithm to classify a mid tier program? What is the metric you are using to compare the volume of studies? Are the residents simply reading 300 chest x rays daily incorrectly?

There is nothing wrong with a resident coming to the defense of their program, particularly when the program put you in a very uncomfortable position in front of the entire radiology community, but try to avoid blatant falsehoods like this.
 
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Apparently they issued a backhanded apology and said they'd keep looking for new ways to replace radiologists.

This is shameful. They are selling the profession to the highest bidder. I urge anyone who applied to UPenn to withdraw their applications or decline interviews. Make it known that what they are doing is not OK.
 

scoopdaboop

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TBH, seems like people overreacting a lot. It's not like all of a sudden Penn will replace all residents with x-ray techs for cheaper... Nor will they train US techs, MRI techs etc. to read only their one modality and replace everyone... The study was dumb, though, yes.
 
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scoopdaboop

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The problem is that it was a study to justify an agenda. Penn is no longner in the bussiness of educating physicians. They are in the healthcare bussiness and that takes priority over any and all other priorities.

But what is the agenda? To replace radiologists? To replace residents? Seems like a bit of a reach.
 
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TBH, seems like people overreacting a lot. It's not like all of a sudden Penn will replace all residents with x-ray techs for cheaper... Nor will they train US techs, MRI techs etc. to read only their one modality and replace everyone... The study was dumb, though, yes.

No, not “all of a sudden.” It will be a slow decline like anesthesia and CRNAs. Hire multiple, far cheaper midlevels, have a radiologist oversee them, charge radiologist rates for all of them. That is the greedy admin dream.
 

scoopdaboop

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No, not “all of a sudden.” It will be a slow decline like anesthesia and CRNAs. Hire multiple, far cheaper midlevels, have a radiologist oversee them, charge radiologist rates for all of them. That is the greedy admin dream.

Okay well for this to happen, several things must be done.

1- Admin/hospitals will have to have schools teaching how to read radiographs
2- They will obviously need to hire radiologists who have to agree to do this

So... if it does happen, radiologists are the one selling out their own profession.
 
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Okay well for this to happen, several things must be done.

1- Admin/hospitals will have to have schools teaching how to read radiographs
2- They will obviously need to hire radiologists who have to agree to do this

So... if it does happen, radiologists are the one selling out their own profession.

Which admins can either

A) find greedy dinguses willing to do so

B) threaten jobs if they don’t do so

C) write it into new contracts as part of their duties


Hopefully the backlash is strong and swift. Looks like all the radiologists I follow on Twitter called it out.
 
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When the senior author gave grand rounds about this project at my institution, he showed clips of Twitter posts of the backlash (to a prior paper in which they trained a tech to read MSK radiographs, which didn't make nearly as big a wave as this paper) to point out that they were dumb arguments. Among those posts was my own. It was hilariously awkward. He also couched the argument for radiology extenders by saying there is a paucity of people who want to read chest radiographs (they pay non-chest attendings and fellows to internally moonlight to read the chest radiograph backlog), as well as a paucity of competent residents from reputable programs who want to go into chest radiology. We can only get a bunch of IMGs and they're not sending their best, was the implication. That was probably also awkward for the audience of chest fellows.
 
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The sort of physicians who design these studies are entrenched academics. They're used to having residents/fellows do a bunch of work for them (and signing off after a brief review). To them doubling or tripling their workforce by hiring midlevels to do their work for them is the dream.

They don't care about patient outcomes, physician autonomy, the younger generation of physicians, etc. It comes down to the $$$$$ for them.
 

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The sort of physicians who design these studies are entrenched academics. They're used to having residents/fellows do a bunch of work for them (and signing off after a brief review). To them doubling or tripling their workforce by hiring midlevels to do their work for them is the dream.

They don't care about patient outcomes, physician autonomy, the younger generation of physicians, etc. It comes down to the $$$$$ for them.

Doesn't make sense lol. A resident is cheaper than Midlevels.
 
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Doesn't make sense lol. A resident is cheaper than Midlevels.

The admins and bean counters are foaming at the mouth and drooling at the idea of staffing every service with mid-levels and just having a few physicians to oversee or manage. Don't brush this off so lightly. It's definitely the start of a bigger agenda. When big daddy comes down to the basement to tell you that you now have to train these clowns to save the hospital money, what are you going to do? Quit? Uproot your family and find another job where the same thing will also happen eventually? You have to kill this creep/encroachment at first sign, asap.
 
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The admins and bean counters are foaming at the mouth and drooling at the idea of staffing every service with mid-levels and just having a few physicians to oversee or manage. Don't brush this off so lightly. It's definitely the start of a bigger agenda. When big daddy comes down to the basement to tell you that you now have to train these clowns to save the hospital money, what are you going to do? Quit? Uproot your family and find another job where the same thing will also happen eventually? You have to kill this creep/encroachment at first sign, asap.

You can’t make excuses like IM and gas did. Fight it at every corner because once they’re in place they just lean on you until you completely collapse
 

Gadofosveset

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So - I agree with the idea of keeping radiology with radiologists — but I also see it from the other side as well. It seems to me the difference between this situation and gas is that this is not a way to leverage extenders for profit, but a way to cut losses.

This just seems like Penn’s option to handle increasing studies with decreasinf reimbursement. Other programs (and Penn too?) are working full steam at AI for a similar reasons and to my mind the intended end goal of AI is effectively no different than extenders in the grand scheme of things.

The simplistic answer is always “Hire more radiologists!”, but hiring radiologists to deal with high volume low reimbursement is super inefficient and ultimately a losing proposition. These studies can’t pay their salary and if somehow they could read enough to cover themselves, they would burn themselves out in 3-6 months.

It’s a tough problem. If y’all have a better idea how to deal with this high volume / low reimbursement problem, start developing/publishing it! The radiology world really wants to hear from you!
 
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So - I agree with the idea of keeping radiology with radiologists — but I also see it from the other side as well. It seems to me the difference between this situation and gas is that this is not a way to leverage extenders for profit, but a way to cut losses.

This just seems like Penn’s option to handle increasing studies with decreasinf reimbursement. Other programs (and Penn too?) are working full steam at AI for a similar reasons and to my mind the intended end goal of AI is effectively no different than extenders in the grand scheme of things.

The simplistic answer is always “Hire more radiologists!”, but hiring radiologists to deal with high volume low reimbursement is super inefficient and ultimately a losing proposition. These studies can’t pay their salary and if somehow they could read enough to cover themselves, they would burn themselves out in 3-6 months.

It’s a tough problem. If y’all have a better idea how to deal with this high volume / low reimbursement problem, start developing/publishing it! The radiology world really wants to hear from you!
And you're be there 10 years from now to make sure that these extenders stay within their lane? Cuz, you know, that's literally the definition of creep. It starts with something like this and then they wany more and more.
 

Gadofosveset

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And you're be there 10 years from now to make sure that these extenders stay within their lane? Cuz, you know, that's literally the definition of creep. It starts with something like this and then they wany more and more.

Creep is definitely an issue, but you didn’t suggest an answer to the problem.

If you’re worried about creep into advanced imaging in 10 years then AI is your target. The geniuses working on AI in every area remind me of the geniuses working on the Manhattan project, blithely steaming along not really considering what they’re getting into. Fortunately the AI + extender model is probably not feasible for another fifty years.
 
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Gadofosveset

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And you're be there 10 years from now to make sure that these extenders stay within their lane? Cuz, you know, that's literally the definition of creep. It starts with something like this and then they wany more and more.

And yes, I will be around in ten years, and if we were to pick up some extenders, then I’d keep an eye on them. If extenders make economic sense to cut losses in CT and MRI we are in a sorry state of affairs, indeed. If extenders are being used to leverage profit in CT and MRI, then I agree with you, it’s a danger. I think it takes judgment to know the difference, which it’s probably optimistic to assume people will have, but something has to be done if the water is just continually being pulled out of the pool by CMS and we can’t rein in utilization. A top heavy model will topple over.

Just as a side note, I’ve run a little experiment with myself trying to support my salary with plain film reads. It is sobering. I suggest you try that before getting too dogmatic on this issue. One way around extenders would be to accept lower rad salaries for the inflation in positions needed to cover a proliferation in low reimbursement imaging. That’s an option, but hardly a popular one. And an oversupply of rads is also not going to be a good thing.

These are tough questions. They require responsible leadership and some strategic thinking. I hope we can do it as a group.
 
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If extenders make economic sense to cut losses in CT and MRI we are in a sorry state of affairs, indeed. If extenders are being used to leverage profit in CT and MRI, then I agree with you, it’s a danger.

This seems like the same thing. In both scenarios you are using extenders for economic reasons. In the first scenario it's to turn a loss into a positive and in the second scenario it's to turn a profit into a bigger profit.

If your profit is so small that your salary is 50k is it ok to use extenders? How about if it is 400k?
 
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Gadofosveset

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This seems like the same thing. In both scenarios you are using extenders for economic reasons. In the first scenario it's to turn a loss into a positive and in the second scenario it's to turn a profit into a bigger profit.

If your profit is so small that your salary is 50k is it ok to use extenders? How about if it is 400k?

It’s not the same thing at all. One is maintaining a salary status quo so it’s dangerous, but defensive. Are you willing to take a salary cut to prevent extenders? Train more rads? Work longer hours? The other is leveraging extenders to make more profit. This is dangerous and greedy, but so tempting for people (such as with gas). Academics, PP, PE, no one is too good for this. I’m not behind this at all.

I’m not sure what the second question means.

Again, no answer to the fundamental problem. It’s a tough one. CMS is draining water out of the pool, rads don’t want a lower salary, what do we do about it? Any “solution” seems like it would be a compromise.
 
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It’s not the same thing at all. One is maintaining a salary status quo so it’s defense. Maybe not ideal, but are you willing to take a salary cut? Another is leveraging them to make more. This is just dangerous, but much more tempting for people (such as with gas)

I’m not sure what the second question means.

Again, no answer to the fundamental problem. CMS is draining water out of the pool, rads don’t want a lower salary, what do we do about it? Any “solution” seems like it would be a compromise.

It's the same. You'll be the only one making this claim. No one else will care if its to save 50k or to make 50k. It adds to the same bottom line.
 

Gadofosveset

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It's the same. You'll be the only one making this claim. No one else will care if its to save 50k or to make 50k. It adds to the same bottom line.

Getting out of the red and getting more into the black are two different things. X Rays run in the red on radiologist salaries and will only run redder.

Saying you’re willing to run deeper and deeper into the red to keep an extender out of radiographs is an interesting strategy. Seems ultimately counter productive because you were keeping them out to preserve jobs which are now even more exhausting and not as well paying. We had to save the village by destroying it.

But maybe that saying should be used for creep? Maybe it’s worth blocking all extenders just to prevent any chance of them going after advanced imaging? You know someone is going to try. Again, I don’t see everyone trying to shut down AI when that’s its end goal as well.

The question seems to me to be what to do when covering x Rays with advanced imaging no longer works because of cuts to both, which is what I think people are trying to prepare for. Either salaries are going down or new efficiencies need to be found. I don’t really have an actual dog in the extender fight, but I see the theoretical problem they’re trying to work against. I also don’t totally understand the drama here... someone’s coming for your salary. Always will be. CMS, extenders, AI, PE goons. Simple minded defense seems a losing strategy to me. Just burying the head in the sand. Practicing rads’ve got to navigate this as best we can as a group. The high level of discussion evidenced here shows how well we work as an intelligent group.
 
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Getting out of the red and getting more into the black are two different things. X Rays run in the red on radiologist salaries and will only run redder.

Saying you’re willing to run deeper and deeper into the red to keep an extender out of radiographs is an interesting strategy. Seems ultimately counter productive because you were keeping them out to preserve jobs which are now even more exhausting and not as well paying. We had to save the village by destroying it.

But maybe that saying should be used for creep? Maybe it’s worth blocking all extenders just to prevent any chance of them going after advanced imaging? You know someone is going to try. Again, I don’t see everyone trying to shut down AI when that’s its end goal as well.

The question seems to me to be what to do when covering x Rays with advanced imaging no longer works because of cuts to both, which is what I think people are trying to prepare for. Either salaries are going down or new efficiencies need to be found. I don’t really have an actual dog in the extender fight, but I see the theoretical problem they’re trying to work against. I also don’t totally understand the drama here... someone’s coming for your salary. Always will be. CMS, extenders, AI, PE goons. Simple minded defense seems a losing strategy to me. Just burying the head in the sand. Practicing rads’ve got to navigate this as best we can as a group. The high level of discussion evidenced here shows how well we work as an intelligent group.

This is all semantics. No one has time for that. Radiology extenders don't care. Admins don't care.
 
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Getting out of the red and getting more into the black are two different things. X Rays run in the red on radiologist salaries and will only run redder.

Saying you’re willing to run deeper and deeper into the red to keep an extender out of radiographs is an interesting strategy. Seems ultimately counter productive because you were keeping them out to preserve jobs which are now even more exhausting and not as well paying. We had to save the village by destroying it.

But maybe that saying should be used for creep? Maybe it’s worth blocking all extenders just to prevent any chance of them going after advanced imaging? You know someone is going to try. Again, I don’t see everyone trying to shut down AI when that’s its end goal as well.

The question seems to me to be what to do when covering x Rays with advanced imaging no longer works because of cuts to both, which is what I think people are trying to prepare for. Either salaries are going down or new efficiencies need to be found. I don’t really have an actual dog in the extender fight, but I see the theoretical problem they’re trying to work against. I also don’t totally understand the drama here... someone’s coming for your salary. Always will be. CMS, extenders, AI, PE goons. Simple minded defense seems a losing strategy to me. Just burying the head in the sand. Practicing rads’ve got to navigate this as best we can as a group. The high level of discussion evidenced here shows how well we work as an intelligent group.
Interesting to see a radiologist talking this way. I'm gonna be blunt. What's your angle? You can't honestly believe the garbage you're spewing.

Reimbursement is an issue, AI will have to be the solution. Ceding turf to actual mouths that need to be fed will and always has led to disaster because those mouths consistently want bigger and bigger portions. AI keeps control in the hands of actual physicians, something we're desperately lacking these days.
 

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Interesting to see a radiologist talking this way. I'm gonna be blunt. What's your angle? You can't honestly believe the garbage you're spewing.

Reimbursement is an issue, AI will have to be the solution. Ceding turf to actual mouths that need to be fed will and always has led to disaster because those mouths consistently want bigger and bigger portions. AI keeps control in the hands of actual physicians, something we're desperately lacking these days.

Glad you’re being blunt. That’s something really lacking around here. There’s no angle besides playing devil’s advocate. There’s a lot of touchy emotive freak outs going on over this which tempts me to try out the minority opinion.

AI would replace extenders. They both do the same thing except extenders cost more in every way.

I guess I’m less sanguine about AI because it’s a tool that the owner of the tool will profit from. But who is the owner? If the trend of doctors as employees continues, then AI will not benefit them.

Anyway — trying out a minority opinion. Not really that attached to it, but it’s interesting encountering “They’re taking our jerbs!” freakouts from people who have not read 350 radiographs in a shift. At least I assume they haven’t because then they’d be a little less dogmatic. Ain’t nobody wants that jerb on a regular basis. Training an extender could be a little like training a tech. I bet ultrasound old timers once thought that training techs was the end of rad dominance of ultrasound. Maybe they were right, but nobody wants to scan all over the hospital in the middle of the night.
 
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Interesting to see a radiologist talking this way. I'm gonna be blunt. What's your angle? You can't honestly believe the garbage you're spewing.

Reimbursement is an issue, AI will have to be the solution. Ceding turf to actual mouths that need to be fed will and always has led to disaster because those mouths consistently want bigger and bigger portions. AI keeps control in the hands of actual physicians, something we're desperately lacking these days.

Every profession has sellouts, for a quick buck or two.
 
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So - I agree with the idea of keeping radiology with radiologists — but I also see it from the other side as well. It seems to me the difference between this situation and gas is that this is not a way to leverage extenders for profit, but a way to cut losses.

This just seems like Penn’s option to handle increasing studies with decreasinf reimbursement. Other programs (and Penn too?) are working full steam at AI for a similar reasons and to my mind the intended end goal of AI is effectively no different than extenders in the grand scheme of things.

The simplistic answer is always “Hire more radiologists!”, but hiring radiologists to deal with high volume low reimbursement is super inefficient and ultimately a losing proposition. These studies can’t pay their salary and if somehow they could read enough to cover themselves, they would burn themselves out in 3-6 months.

It’s a tough problem. If y’all have a better idea how to deal with this high volume / low reimbursement problem, start developing/publishing it! The radiology world really wants to hear from you!

Stop trying to chase the scans. Seriously. Let them pile up. You don’t fix the high volume low reimbursement problem increasing productivity. That only leads to lower reimbursement and higher volumes and more burnout.

Your really not gonna get ahead of this
 

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I wonder if Penn will explicitly address this (with propaganda) on their interview days. I saw they doubled down in their PR statement while withdrawing the article. Contrary to the above, while they could theoretically take a hit in applications I think they're still too solid of a program for most folks to pass on.

I personally have no skin in the game. Just curious.
 
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I wonder if Penn will explicitly address this (with propaganda) on their interview days. I saw they doubled down in their PR statement while withdrawing the article. Contrary to the above, while they could theoretically take a hit in applications I think they're still too solid of a program for most folks to pass on.

I personally have no skin in the game. Just curious.

The problem is that it’s not a mortal wound to its reputation. Penn has too big a name to fall even after stupidity like this.
 
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Put out by Penn....by and MBA.....

Guess that takes Penn off my list of places to apply.
As an anesthesia resident, I absolutely implore you all to not give an inch to any mid level. You don’t see any surgeons letting their APP do any more than close a skin incision or burrow out a vein. They are kept tight to the chest where all decisions run through them. Yes that means surgeons have horrible quality of life but they haven’t sold out their specialties unlike every other one! Especially in anesthesia where people honestly became lazy to sit their own cases and more money can be made. But our specialty got way greedy and allowed APP to run the show 4:1 rooms, independent practice, etc. In the ED and the medicine world, it baffles me how much we rely on mid levels to get the job done. And it’s usually because in all honesty, we are lazy! It leads to worse patient care and inefficiency and residents are worse off in the long run. The only “mid levels” should be residents in training. We need to pay our dues and that’s that. Or else we fall to selling our own selves out by training our replacements. As a senior resident, I’m only letting the student nurse anesthesia do procedures because I let them, not because they deserve it. And I’m right there with them as they do their art line, IV, intubation etc. they aren’t doing anything independently. If it were up to me, they wouldn’t be doing any procedure. And just assisting me as what they were created to do. Hand me the tube, help set up the room, tape up my art line, give me a lunch break when the case is stable. That’s what a physician extender is. They must not do what the physician was paid to do expertly.
 

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