Transforming the Way Radiologists Learn - Daniel Arnold, CEO of Medality

Shiv Gaglani: Hi, I'm Shiv Gaglani. The use of imaging is a cornerstone of modern medicine with technological advancements in the field giving providers more options for diagnosis and treatment all the time. Today in Raise the Line, we're going to take a look at how radiology fits into the broader healthcare picture, and why training and medical imaging is so important to improving patient care. We'll tackle those questions and more with Daniel Arnold, the CEO and co-founder of Medality formerly known as MRI Online. Medality is a practice development platform that helps radiologists, upskill and high-growth advanced imaging areas and modalities. Daniel holds an MBA from Harvard Business School where we were actually classmates and friends and worked previously at Google developing new products in the tech sector and at Accenture in strategy consulting. He also hosts his own show The Radiology Report Podcast. So Dan, thanks so much for taking the time to be with us today.

Daniel Arnold: Thanks, Shiv big fan of the show and excited to be on.

Shiv Gaglani: Awesome. We'd like to get started by just having our guests in their own words describe their background. So, what got you interested in your education journey, and then ultimately, business school and now Medality.

Daniel Arnold: Sure. I actually studied engineering in undergrad at Northwestern, but was always more interested in business and entrepreneurship. It just happened to be my strengths were in math and science.  So, I studied Industrial Engineering, which is around how to apply math and science to business problems and then went into strategy consulting for Accenture, where I helped large companies with a range of supply chain operations, strategy, technology projects. But ultimately, I didn't love working for large companies, and always wanted to do something a little more innovative and entrepreneurial, and had an opportunity to work at Google launching new products. So, kind of working at startups within Google. 

One of the startups that I worked at within Google was a product called Google Helpouts and the idea behind Google Helpouts was that every day people come to Google asking them millions of questions and oftentimes, if you could connect a person to an expert, they can answer your question more quickly. For instance, I'm struggling with my math homework, or I can't get my code to compile, or how do I install this Samsung TV...you could spend an hour on Wikipedia or YouTube, but if we could just connect you to an expert t Google Helpouts -- which was kind of using their hangouts technology -- we could solve their problems. 

It was a really clever idea and I helped start the business within Google and I was overseeing all their education efforts. The idea was to build an online tutoring marketplace to get help with math and science and language. It was exactly the right idea, but ten years too early. This was back in 2011. It was before Zoom, it was before micro-payments, creator economies...like all these trends were exactly right and it is just timing is everything and also starting a company within Google within a big company is really challenging. 

I learned a lot there and I really got my front row seat into how education was changing and how access to information via the internet was going to transform the way we learn. As I mentioned at the start, my goal was always to start a business and so decided to get my MBA and the goal, post business school, was to start a company or join an early-stage startup. But as you know, in medicine, you're at the mercy of residency and really, all the different steps in that process. 

I was engaged at this time to my now wife, Taylor, who was finishing up med school in Cincinnati, and she didn't know where she would be next. So, we were waiting eagerly for the match and I was like, "How can I start a company? I don't know where we're gonna live or what's gonna happen." This is before remote work and so I moved to Cincinnati and said, “I'll take on some consulting projects here in Cincinnati while we figure out where you match.”

During that time, I hooked up with Dr. Steven Pomeranz, my co-founder and the chair of Medality, as well as the chair of ProScan imaging at the time. He's first and foremost a radiologist, so 90% of his time is practicing medicine. But at the time, he was going around giving lectures in person and he'd fill a conference room in Vienna, Austria with two hundred people to hear a lecture about shoulder MRI and I thought, "Gee, that's neat. Have you thought about putting these lectures online?" And he's like, "Yeah, I have." Because of my experience at Google, we thought, “Hey, you know, there's some complementary skill sets there. I think I know how to how to do this.” So, that's where the company was started. 

I'll tell you a little bit more about how we got from here to there, but that's how I ended up in medicine. Never would have guessed that I'd be in healthcare, or education, per se. I always wanted to be in tech in business and I found this amazing intersection between these fields where the work that we're doing has a really big impact and I'm scratching my entrepreneurial itch.

Shiv Gaglani: Yeah, that's awesome. And I agree. Going back to your experience at Google in terms of timing, we had a guest a couple months ago who started Straighter Line in 2005 or 2006. It's a very successful company that reduces the cost to get online college credits, but he started well before anybody knew what a MOOC was or Coursera or EdX existed. He had this great quote which was, "If you stick around long enough, your timing is perfect." Certainly, early to the party with regard to online tutoring on demand. So, it's good to have those learnings and realize that there's an element of serendipity and luck that comes with all of this stuff as well. 

So going to Medality and the founding story of how this physician you've teamed up with went and did lectures in person...when we met up in Park City a couple of months ago, I talked to you about one of our investors and my advisor, Aaron Skonnard, who started Pluralsight. He was teaching computer science in person, giving live lectures, and then decided to get it all online and became a very successful online learning company in the corporate learning space for coding and upskilling. Let's get more into Medality because obviously, there's been an explosion in online learning and healthcare. That's what Osmosis has been focused on. Tell us more about the field of radiology, why it's so important that people are learning the shoulder MRI, what you think about how that's going to evolve over the next five, ten years, too, just given everything we've learned about and talked about with regards to say AI imaging, etc.

Daniel Arnold: I knew nothing about radiology before I started, and I'm learning more every day. It's an amazing field. Imaging has really become the tip of the spear of the patient journey from diagnostics to cancer staging to surgical planning, and really taking a patient through their care plan. Oftentimes they might be getting a lot of imaging throughout their care journey and so nearly all treatment pathways start with some amount of imaging. If you're a patient today, chances are you're being impacted in imaging. 

Despite how important it is, Shiv, you'd be amazed at how often doctors get it wrong. Studies show over 20% of the time that a subspecialty radiologist over reads the first read of a patient's imaging. They get it wrong. They disagree with some of the core findings that would have changed this patient's treatment plan, and so despite it being done millions of times per year, we get it wrong a lot. So, what happens when you get imaging wrong? Well, at its most banal, you get it wrong and you're getting ping ponged from specialist to specialist. You don't know what's wrong, you keep trying to figure out what's wrong with you. At its most serious, it's a misdiagnosis that could have really changed the trajectory of someone's life, whether it's a missed cancer and an opportunity for early prevention, or some other more serious things that you could find. So, it's a really high-impact field for patients and getting it right is really important.

That’s what motivates us, and as you think about imaging, it has grown tremendously. The demand for imaging just continues to grow unabated. Post-COVID, you were facing one of the most serious labor shortages in radiology we've ever seen and what's really exciting about AI is all the promise. There's been a lot of discussion around how AI might be able to do many of the tasks for radiologists. What's actually happened is AI is adding work to the radiologist plate because now when you're getting stroke imaging, the AI is giving you additional data and information that's really important for you to consider. When you're getting your cardiac screening, you're getting additional information to consider. 

Over time this will change and there's hopefully some imaging that we can automate and release from the radiologist workload but, you've got imaging going up, up, up and you've got AI coming and bringing change, so people need to learn and continue to improve at this field. Maybe the final point on this is, you know, people thought in an ideal world, you do radiology, you do residency, it's four years, then you do a fellowship and go even deeper and might do neuroradiology or musculoskeletal radiology. The hope is that anytime you get imaging done, you're gonna get seen by a subspecialty-trained radiologist. The reality is over 98% of radiologists in this country are fellowship-trained, meaning they've gone deeper in a level. Yet over 55% of radiologists practice in three or more specialties and 85% practice in two or more specialties. So, just because you've done subspecialty training doesn't mean that you can only practice what you've learned in your specialty. As the field evolves and changes, you can't just rely on what you learned in residency and fellowship. You need to continuously stay up to date.

Shiv Gaglani: That makes sense. Especially as new patient loads are getting higher. There's an elderly population, the demand for radiology is going up as you're saying and certainly the number of new med schools or GME radiology spots has not increased. I'm curious from a user perspective, is it mostly just radiologists? Can you tell us a bit more about who Medality reaches and how many courses you have? Do you work mostly directly to the radiologist, or is it B2B to radiology practices and health systems? Give us a sense of some of that.

Daniel Arnold: Our mission is to transform the way radiologists learn and thrive. Over 95% of the people practicing on our platform today are radiologists. Someday our mission will expand to include additional fields of medicine. But what really makes radiology different, and Medality different, is our core focus on understanding the radiologist's challenges and building case-based simulation courses that enable them to practice and improve. Our goal, by the way, is to make it easy for radiologists to learn a new subspecialty in just five minutes per day. The way that we do that is through our case based micro-learning courses. 

For example, let’s say you're trying to learn shoulder MRI. You are presented with a case of a patient who was playing football and got tackled and went to the ground. Here is their shoulder MRI. What's wrong with them? You scroll through that shoulder MRI on a phone, iPad, or workstation and it completely mimics the experience of practicing radiology in the cloud. From there you give your best shot at the diagnosis and then you have an expert world-class radiologist like Dr. Don Resnick -- who wrote the book in musculoskeletal (MSK) radiology -- explain to you in detail how to approach that case. 

That approach of teaching really mimics the experience of a resident or a fellow training side by side with an attending online.  So that's what makes our product unique. 

Then, because it's short -- similar to Osmosis videos, two to four-minute videos paired with the simulation training -- it's really easy to do a little bit each day and take on new skills. We started out in MSK, but we've expanded to cover all modalities so we have courses in PET, CT, ultrasound, breast tomosynthesis, and so many more. That's why we've changed our name from MRI online to Medality to reflect that expanded scope. We have over a hundred courses covering pretty much anything that a radiologist needs to know in the field of advanced imaging. When I say advanced imaging, what does that mean? It's not just what residents need to know to pass their boards and their clinical rotations. It's actually what private practice radiologists out there every day -- your community radiologist in Idaho trying to build a practice and keep up with new things coming out all the time -- you can come to Medality and learn those skills and integrate them.

Shiv Gaglani: That's really great to hear. Speaking of lifelong learning and the things that make radiology unique, when we were walking about this concept of remote fellowship and some of the things that you saw during the pandemic, in terms of how you started kind of online Grand Rounds...can you talk to us a bit about some of the innovations, particularly those brought about over the past two, three years, as the COVID pandemic has changed everything?

Daniel Arnold: Yeah, you know, right around the time of the pandemic, our original plan was that we would fly people into our studios and build our courses that way, and that people would love to do that. And it turned out with the pandemic, we thought, "Gee, no one's gonna travel to our studios anymore." At the same time, residents were no longer able to go in for lectures and so there's this huge gap in the market. So, we started a daily lecture series called Noon Conference that to this day persists. We put it on each week, and it's been attended every week by thousands of radiologists around the world. It's a free resource that we put on there. It has enabled us to have over four hundred of the world's top radiologists from pretty much every academic institution share their knowledge with the world. We make that a free resource to the radiology community and then we pair that with our products like our mastery courses and remote fellowships for people that are looking to deepen their knowledge. S

An example of how we do that is an area like prostate MRI. In the past, prostate MRI didn't exist. It's a relatively new technology and it's growing rapidly. It was actually one of the fastest-growing CPT codes over the last five years. It used to be the case that if people wanted more intensive treatment for elevated BPH and risks of prostate cancer. But the reality is everyone over the age of sixty has prostate cancer and it turns out in a majority of cases, you actually don't need to cut out the prostate. You can watch it on MRI over time. As a result, there's been an explosion in prostate MRI. 

When a new field like that emerges, but you were in residency fifteen years ago, how do you take that and apply that to your practice? We created a mastery series course in which there are short simulation courses, and then we have what's called a remote fellowship where you can actually read those cases and you can dictate a report the same way that a radiologist dictates a report today. That report then gets graded by a sub-specialist giving you feedback like "Shiv called it a PIRADS 3. It's actually a PIRADS 2, and here's why." Anytime you do these cases, it's really important for the patient that you comment on these key measurements and the urologist is going to need to know this for surgical planning and so they're giving you very catered feedback on this. 

You can do this from home integrated into your clinical workflow. I can actually pull these cases up at work and learn on the job. You were asking who are customers are. Is it individual radiologists or residents? It's actually radiology groups. Let me explain why. One of the biggest trends in radiology is consolidation. The average group size has more than doubled over the past ten years as groups have leveled up. So, if you're looking at prostate MRI being the fastest growing CPT code, I need to offer this in order to serve my patients effectively, as well as grow my business. But I don't have anyone on my staff that can confidently read prostate MRI, right? 

So I'll look at my group of radiologists, identify people that are capable and interested in learning this skill and then give them the tools that they need to learn it. Then through Medality, they actually get data showing that, "Hey, you know, when Shiv started his remote fellowship, he was missing two or three cases out of five. He's now no longer missing any cases. He's reviewed over seventy-five prostate MRI cases and twenty-five of them have been graded by a specialist. He's ready to go." That gives you the confidence then to plug your radiologists into this new field and grow your business. That example in prostate MRI is happening across the board if you look at areas like the growth in tomosynthesis, breast MRI, cardiac CT and I could go on and on. So, those are the types of tools that we provide.

Shiv Gaglani: I love that. That's really great and the fact that you're so close to practicing clinicians who you can upskill. There are three big things that make health education different than language education or math education. One is, it is high stakes. That's probably the biggest thing. If you forget how to factor or conjugate a verb, you may embarrass yourself, but it's not going to hurt anybody. Whereas if you misdiagnosed somebody, for whatever reason, that could really hurt their life and your career in the process. Second, it is dynamic. We constantly are finding new modalities and generally are evolving our understanding of the human body, new treatments, etc. So that's a separate change. And third, it's too vast for any one person to know which is why we need computer assistance in general clinical decision support. 

The holy grail of health education given these is, I think, ultimately patient outcomes. Are we getting higher quality care, and ideally lower-cost care, and more access? How do you define success for Medality? Is it just the number of radiologists you've trained? Obviously, you're gonna expand beyond some of the MRI work -- that's part of the name rebrand but are you able to do any studies where you're gonna look at radiology groups that have adopted Medality versus those who don't and what are they reporting in terms of outcomes?

Daniel Arnold: It's a great question, Shiv, and it's one we ask ourselves all the time. I'll tell you, one of our core values is "driven to help doctors save lives." At the end of the day, our mission is to make doctors more successful through our platform, driving better patient outcomes. We measure that a few ways. We're continuing to learn and grow in this area in particular.

The first way that we measure it, which is pretty interesting, is we survey doctors after each course. We say, "Hey, is this going to change the way that you practice? Yes, or no?" And secondarily, "How many patients do you treat that would be impacted by this course each day." We actually just hit an amazing milestone: over ten million patients would be impacted over the last two years from the courses that we do, and we're just getting started. The reason radiology is so impactful is the average radiologist might be doing fifty to a hundred patient cases per day. So, if you think about the impact of changing quality and behavior of a radiologist, you can have a lot of impact in the world. 

The next way that we're looking at this is we look at our remote fellowships where we can see in a simulation environment what percentage of the time are they getting things right versus wrong. What we see is about a 200% increase in accuracy from the start of their fellowship to the end of their fellowship from that course. We measure pre and post-test. We've actually got some papers that we're going to be writing in the next year where we've partnered with both academic programs and practices to measure this and get some results out. But some early data has shown that through our Emergency Department preparedness course -- where we help people prepare for covering the ED and covering call -- we're seeing an increased confidence and increased accuracy from about 25% before they start our courses to around 75 to 80%, after. So, just tremendous results across the board. 

What I'd love to do, as I think longer term about this, is figure out how to integrate our technology deeper with practices who may partner with payers or the life insurance companies to say, "Hey, the number of claims against these people have gone down as a result of the work that you've been doing." So, we're trying to deepen that. I'd be curious to hear how others in the space have approached this, but I’m really excited about the early results here.

Shiv Gaglani: Totally. I love that. One group I can connect you with if you're interested -- they were one of our large investors at Osmosis -- is a medical malpractice insurance company called Coverys. They have invested in several companies, including our friends at VisualDx, which started off with dermatology education. The whole point was to improve diagnostic capabilities of dermatologists. But it's expanded beyond dermatologists, too. Similar to how you can get a reduction in your premium if you take a driving course or put a safety device in your car, maybe you could get advantages in your medical malpractice insurance for radiologists who perform better using Medality if there's research to back all this stuff up. That would be an ideal way to align incentives with the different stakeholders in a very complex healthcare field. 

Daniel Arnold: Nearly all radiologists will face a malpractice claim at some point in their career. It's one of the more litigious specialties because you're looking at so many images. You might look at one person's cardiac CT and then have to diagnose a cancer in a different part of the body that isn't the reason that they came in, and you're looking at a thousand images while you're doing that. You do that a hundred times a day, so being trained in this is so hard. That's where also I think education plus AI can really drive profound patient outcomes. 

Shiv Gaglani: What are some of the other major long-term trends in radiology that you want to mention here? Again, AI is top of mind because of all the things we've heard, but Tom Friedman also popularized the fact that radiologists in India were being hired by U.S. hospitals to do overnight imaging. What are some other long-term trends?

Daniel Arnold: Some of the advances coming are just so amazing. I mean, the advances in stroke imaging are truly lifesaving. I'm sure you're familiar with the phrase time to brain, and just how important it is. Imaging plays a central role there. You require good imaging results in order to figure out if a patient is susceptible to those drugs and so just in the past few years, the way that AI plus Medality advances have come together in a cross-care way bringing together the neuro interventionalist, the ER doctors, the radiologists...those types of things get me really excited. 

There's a new one coming out in cardiac CT. They've finally decided that cardiac CT is a first-line treatment for chest pain and can prevent early heart disease and heart attack. As a result, there's going to be explosion in cardiac CT imaging, which is going to save lives. Those are the things and trends that I get excited about. Some genius at Harvard, or Penn or Hopkins has uncovered the best way to treat patients and then they go, “How do we disseminate this information as quickly as possible to drive change?” I think tools like ours can really, really help with that. Because in the past, you'd be relying on people eventually finding the time to go to the course. And by the way, it's not just education. You also need to help people understand how to integrate this technology into their business model in a way that will help them continue to grow their business. If you say "Hey, you should adopt this technology, but it's going to cost you money, it's gonna slow you down, and patients aren't gonna like it very much," well, that doesn't really work. So, being a part of the puzzle around how we disseminate new lifesaving technologies is what really motivates us and gets us excited. 

One of the other big trends I think we are helping with is there's been a massive consolidation in radiology. One of the biggest groups in the field is Rad Partners. They now have 10% of the market. They didn't exist five years ago, to put this in perspective. So, they went from zero to three thousand radiologists relatively overnight. This has caused a lot of consternation and fear among radiology groups who want to maintain their independence. Well, to be an independent group as a ten, fifteen, twenty- person radiology group is incredibly complex in today's environment where not only you have multiple modalities from a hardware perspective – you’ve got to have MRIs, CT, PET all these different things – but you also need to think about how do we integrate AI? By the way, everyone wants their images available instantly on their phone. They want reports in minutes and hours, not days and weeks and so how do you provide that level of service to a hospital or to a bunch of hospitals as a small group of fifteen? That's really, really hard and so if we can provide educational tools that enable them to stay up to speed and maintain their independence longer and faster, that's something we really want to help with.

Shiv Gaglani: That's awesome, and that's something certainly that we don't learn that much about in med school, or even residency, which is the actual practice of business and medicine. So certainly, that's something interesting, as a side benefit of companies like Medality. We're coming up on time, so I have just two last questions for you. The first is, what advice would you give to our audience listening to this about approaching their careers? Most of them are going into careers in healthcare, but some of them clearly may want to be entrepreneurs in health education like you and me, or you know, contribute to the health care system in other ways. 

Daniel Arnold:  If you're going into medicine, focus on continuing learning and building those habits early. No different than you and I. We both like to exercise and we always find time during the day to hit the gym. You’ve got to find time each day to hit the online education. I think building those habits early can have a long-term payoff for what you're trying to do. I think that would be like the shameless plug. 

I think one of the things that you learn in business school and at Google certainly is you have to solve a problem. You have to create a product that people will buy. Both of us took that approach in building our businesses. We didn't just have an idea on a piece of paper, and then go raise money, and then go build it, right? We built something janky, overnight. It didn't look perfect and we sold a few and it was "Hey, this is kind of good.” That's certainly how we built this business...brick by brick. We built a course, sold a course, built a course, sold a course. Never hired an engineer until we were a few years into this thing. So, we bootstrapped our way to this business. It's the only way I've known how. I think that's number one is, you can certainly bootstrap your way into most of these businesses.

Number two is, my founder and I have very complementary skill sets. Oftentimes you have three doctors come together who want to start a business. You have three business people that want to come together and start a business. But the real magic is when you can get a business person and a doctor and an engineer to come together and start a business. That's where places like Harvard -- and where you ultimately took your medical training to then go get an MBA, I think -- was really helpful for you to develop these complementary skill sets to your team. I think that can be really helpful advice for any doctor who's thinking about getting started. Probably don't start the business with your current residents. Go hang out in the design school, the engineering school or the business school.

Shiv Gaglani: It's a really interesting point and one reason I think places like Stanford have done so well, with entrepreneurship, is it's part of the culture. But also, if you'd literally go to the campus, the med school and the engineering school and the business school are all very close to each other. Versus at Hopkins, it's like many different campuses. As you know, the Harvard School of Engineering just moved right next to Harvard Business School. That's not a mistake. They're doing that intentionally so that the really smart engineers get to know the really ambitious and hustling MBAs, and together, they create magic and obviously, the med school tries to send people over and vice versa. So, it's really interesting, and a really good point -- how that serendipity of having these Brownian dots connect can lead to really good outcomes. Is there anything else that I haven't asked you that you'd like to share with our audience before we let you go?

Daniel Arnold: I think not yet. But have me on the show in two years -- maybe at eighteen months -- so I can take the lid off some of what we've been up to and our business will have grown and evolved leaps and bounds. I can't wait to share that with you.

Shiv Gaglani: That's awesome, Dan. Well, I'm really excited for you and everything that you and the team are doing at Medality. It's really important work and certainly something we'll keep a close watch on and see how we can partner, too.

Daniel Arnold: Awesome. Thanks Shiv.

Shiv Gaglani: Thanks again. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise line and strengthen our healthcare system. We're all in this together. Take care.