The Honorability of Moving Goalposts in Radiology

I recently watched a documentary about some folks who can make serious money at blackjack tables. They call themselves “advantage players,” meaning that their methods give them an advantage over the house.

Card counting is only one of the tricks they use. They have other methods without having to resort to outright cheating. It all comes down to probability. A brief glance online tells me that a typical casino has about a one percent advantage over a competent blackjack player (more like two to four percent if the player makes an average number of mistakes). An “advantage” player can move those odds to around one percent in his or her favor.

One percent might not sound like a lot, but it adds up over time. After all, those glitzy Vegas monoliths didn’t get built with spare change found between couch cushions. You can imagine why they don’t much like the idea of gamblers messing with their profit margins by turning the tables on them.

A big chunk of the documentary focuses on how the casinos react to advantage players. Again, their methods tend not to be actual cheating (which is, by the way, a felony in some states) but from the casino’s perspective, it might as well be. They don’t have to prove you were doing anything wrong if they decide you’ve been winning too much. They can just tell you you are not allowed to play any more blackjack or kick you out, and maybe ban you for life. The documentary went into some of their less savory reactions too.

When you’re watching a documentary, it’s pretty easy to be biased in favor of whoever the show is focused on. I’m sure if they did a show from the perspective of the casino managers, it would be different. However, watching this thing had me somewhat sympathizing with the players. Here are these massively wealthy gambling houses raking in untold millions from the vast majority of their guests, and when some person finds a legal, reliable method of pocketing a few thousand, they play the dirtiest pool they can to prevent him? How dishonorable can you get?

Stepping back from the casinos a bit, though, is it really all that out of line to adapt to changing times? That is, if you had a strategy, even a set of rules, that worked for you until circumstances changed to make your approach self-destructive, is it honorable or just stupid to keep plugging along the way you were going while your livelihood spirals down the drain?

For instance, longtime readers of this blog may recall that I spent almost five years of my early post-fellowship radiology career in what was supposed to be a partnership opportunity. The track was four years and went smoothly enough. Heck, I will toot my own horn and say I more than proved my value. The managing partner went to far as to proclaim me a “pillar of the practice” during my third or fourth year.

(Editor’s note: For related content, see “Seven Personal Truths from Charting My Own Radiological Course” and “Career Changes and the Value of Perspective.”)

When it came time to live up to their end of the deal, however, they moved the goalposts. Over a course of months, there was plenty of talk about “opening up the books” and getting their lawyers and accountants on task, but it all turned out to be a bunch of foot dragging. After a few rounds of politely asking for updates, I diplomatically cornered them, and they reluctantly presented what I have called a “fake” partnership. It was a token, non-voting share of Corporation A, which was an unprofitable entity fully owned by Corporation B, which was also owned by Corporation C. (No, I wasn’t getting shares of B or C.)

From my perspective, this was about as slimy and dishonorable a move as could be, and it was why I left that place. Perhaps, behind the scenes, they had other things going on that would have made it seem less dishonorable and more practical had they confided in me.

As it was, by leaving them, I moved my own goalposts. Perhaps they considered that dishonorable behavior on my part. I have known more than a few rads (and non-docs) with the idea that the honorable and respectable thing to do is to plunk yourself down in a given group and stick with it no matter what. That makes no sense to me. I’m more of the mind that it’s not a matter of honor to sit still when others treat you badly. (It might be strategic in some situations, but that’s another matter.)

Goalposts get moved all the time. Worklists get lighter or heavier, on-call needs get more demanding, reimbursements fluctuate, referrers demand new things, etc. If you’re getting more asked of you and/or less given to you, it can seem pretty dishonorable: You had a deal and now they’re telling you they intend to change it. That also goes if you’re running a group, and one of your rads starts demanding a better deal for himself or herself without producing anything to merit the increased compensation.

How things are presented can greatly impact the flavor of (dis)honorability.

Is the goalpost movement being presented at the last minute as a “this is happening, so deal with it” diktat? Alternately, is there advance notice and a sense that the reasons for the change are being shared with the folks on the other side of the table? Do they have a realistic opportunity to ask questions and perhaps propose alternative ways of moving the goalposts that will accomplish the same ends?

Is there a counterbalance for the change? In other words, if you’re asking more from people, are you offering them ways to benefit from it so things don’t seem like a one-way street? As an example, telling your rads that they’re going to have to work another weekend each month might go down better if it will boost their paychecks a bit or that any excess shifts done this year will count against next year’s requirements after some successful recruiting.

Are the goalposts being moved for everyone? If people are told that lean times require pay cuts, they might handle it better if they see that executive comp is taking a haircut too. Rads having to cover more nights and weekends are likelier to consider it a “team effort” if they see their leadership taking an equal share of calls and might be even more impressed if those leaders are visibly taking extra shifts, logging in to assist when they’re not even on the schedule, etc.