Eric Postal, MD

It might seem strange that I’d feel the need to advise fellow professionals to watch their language like this. We’re all respectable adults, yes? But you’d be amazed to hear the way some people talk…and words matter. Rightly or wrongly, people judge you by the ones you use.

I’m, therefore, here to advise you: Try to remove that nasty little 4-letter F-bomb from your repertoire. Under most circumstances, the word “fair” won’t help you. Even if it’s modified with things like “un-.”

I recall an episode from early-ish residency. We had a two-tier system for covering call, where junior and senior residents split responsibilities, and it was time for me to take over XR. I was unpleasantly surprised to enter the reading room and find that the now-departed senior had left a massive stack of films (yes, we were still using those) on the counter. They’d accumulated over a course of hours on her watch, but she’d left without looking at any of them.

I felt the need to tell the attending who’d just arrived for reading-out that this was not my mess…mostly because I didn’t want him to think I was slacking. Part of me also wanted him to know that she’d shirked her responsibilities. (It wasn’t the first time she’d demonstrated a crummy attitude in such regard, and had more than once left other residents in the lurch…evidently thus far without repercussions.)

The attending didn’t much seem to care, dismissively saying, “She’s old, and she’s tired.” I was disappointed by this…but I don’t consider it evidence that I’m an evil, vindictive individual. I’ve previously referenced in this column that humans are hard-wired to seek justice; some articles covering the matter refer to the “revenge center” of the brain. Functional MRI actually found circuits involving the amygdala and the dorsolateral prefrontal cortex, activated when subjects experience or just witness acts of unfairness.

So we’re physically set up to recognize and react to unfairness. Why not point it out when we see it? Especially if we feel we’re the ones being treated unfairly?

Because it wouldn’t change anything. At least, not in ways we’d want.

“Fair” is an entirely subjective concept. In an awful lot of circumstances, my “fair” isn’t going to be the same as yours, because we’ve had different lifetimes to form the concepts for ourselves. If I say that something you’ve done, or are passively benefitting from, is not “fair,” it’s almost certain that you’ll disagree.

Suppose you recognize that my accusation has merit. It might make you feel guilty or otherwise uncomfortable. You might have a cornered feeling: I’ve expressed a valid point that you unjustly have X or did Y, and you don’t have a reasonable retort to defend what you’ve got. Either you relinquish it (but you don’t want to), or you keep it, exposed as willfully benefitting from unfairness. You’re probably going to resent my putting you in this position…and might decide to make me pay for it later on.

Or you truly believe that I’m wrong about the unfairness. Maybe you try explaining to me why that is, maybe not. Either way, there are two people bashing their contrasting senses of what’s fair against each other. Nobody’s going to change their mind. One or both parties might be so unable to imagine the other’s perspective that they’ll believe the argument of “fairness” to be disingenuous, a manipulative path to ulterior motives.

Then, of course, either or both might simply resent the conflicting opinion: Who are 

 what’s fair here? How are your values any better than mine?

Griping about fairness can also do the complainer other disfavors. Even if they manage to do it without sounding whiny, it makes them look weak. They are essentially saying that they want something, but can’t get it for themselves. Even appealing to a higher authority to get it for them, they aren’t supporting their case with evidence or other logical points—they are depending on the magic word “fair” to get their way.

Such authorities, and indeed others interacting with a frequent “fair”-er, quickly develop fairness-fatigue. “Life’s not fair” isn’t just a parental parry against squabbling siblings, it’s actually helpful advice (which, at that age, tends to fall on deaf ears). But, later on, some folks might just learn the lesson: Avoid the F-word whenever possible.

Getting back to that situation with the stack of neglected X-rays, I know I didn’t say anything to the attending about fairness. Even if I‘d bothered to track down and confront the senior resident, I wouldn’t have used the word with her, either. It was a couple of decades ago, but even then I’d lived long enough to know that it wouldn’t have helped my case. Indeed, it probably would have taken me down a notch in their eyes.

Better, instead, to support your side of things by showing your audience what they need to conclude 

 what is fair. Persuasion has been nicknamed the art of “letting others have it your way,” and that’s a more effective route. Babbling about what you think is fair won’t help and might actually hurt your case. But if you can present your facts in a way so the other side assembles them to arrive at their own sense of “fairness” that meshes with yours…you can win without even fighting.

Follow Editorial Board member Eric Postal M.D., on Twitter, 

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Rely on facts rather than persuasion when dealing with fairness.

The F-word: Think It, Just Don’t Say It

A recent thread on a radiology forum began with a rad whose group was thinking of adding some daytime teleradiology shifts. He asked what might be an “appropriate daily rate” for a shift of X hours, reading Y RVUs, weekdays versus weekends.

Forums being what they are, I expected a lot more heterogeneity in the responses than there turned out to be. Sure, there was some typical naysaying (“That’s too many RVUs for that number of hours!” “Why can’t you guys do your own work? Teleradiology is evil”)…but most answers were along the lines of needing more detail. What sort of cases were to be read, was this to be full-time or part, etc.

It’s always reasonable to seek more information when analyzing a situation to give advice and solve problems – but especially when the analyzer(s) have abundant first-hand experience with the subject at hand and know what questions to ask. Rads know just how many variables can factor into this situation. What might make sense and be a perfect solution for one group might be a train wreck for another.

In other words, one size most definitely does not fit all.

It’s temptingly simple to approach that way: Hey, our group has more RVUs than it can handle or expects to in the near future. Whatever revenue those RVUs would bring us if we could read them, let’s offer something short of that for one or more telerads to pick up the slack. Anything extra we retain is gravy for us.

Sizing up a situation so simply makes for simplistic solutions. Failing to notice complexities—or foresee any coming down the line—has a way of making those solutions less elegant, even problematic to the point that they aren’t really “solutions” at all.

Such complexities can be as subtle as preconceptions—or lack thereof—in the minds of the group members thinking about hiring their own teleradiologists. Consider a question as simple as, “What do you want a telerad to do for your group?”

Most wouldn’t have an answer beyond taking care of their RVU allotment. Maybe give a little lip-service to things we’d all expect of teammates and employees: Read accurately, be helpful and courteous to referrers, show flexibility to accommodate quirks in the workflow and schedule, etc.

Digging just a little deeper, one might find that there are serious differences in philosophy. Ones that, if not addressed before shaping and instituting the group’s telerad-program, will be way harder to reconcile later on. Some soul-searching in advance could potentially reveal, if not iron out, some of these differences…but often doesn’t occur when it seems a simple solution is already in sight. (Or did you think that satisfaction of search—“happy eyes”—was only a thing when looking at images?)

Some framers of a telerad-constitution, for instance, might take it as a given that the offsite workers are not real members of the team and never will be. They’re being taken on as hired guns, and in exchange for the privilege of reading from home they should never expect to approach parity with onsite members in any way: compensation, authority, you name it.

Others might not see that as a tenable approach. They think everybody representing the group should consider themselves members of the team for the long haul—something that won’t really happen if they’re permanently treated as second-class citizens. Such a hired-gun telerad might not be enduringly loyal to the group, which could have all sorts of undesirable fallout…not the least of which is being that much more attentive to offers from other groups.

Similarly, there might be different ideas about what sort of work the telerads are going to be doing. Some onsite members of the group could be taking it as a given that the whole purpose of hiring offsite help is to churn through the overflowing worklists. Priority one: Get those cases read! Don’t waste time with long-winded, academic-grade reports.

But, again, other members of the group might be thinking differently. The telerads’ work is going to be in the name of the group, and the group should be maintaining certain standards. Is the group really going to hire telerads aimed at quantity over quality?

Some members of the team might even have hoped that leveraging telerad would let them take on brilliant subspecialists, “go-to” guys for tough MSK or neuro cases. Or a peds rad, since the group doesn’t currently have one. Such a maven might not mesh so well with the workhorse role that other members of the team have in their minds.

Months or even years down the line, when the telerads have been on board for a while, the onsite rads might come to realize that their differences in expectation are going to be difficult, if even possible, to reconcile. That can be downright disruptive if the group’s dissent is split in anything close to a 50-50 divide.

Meanwhile, depending on which members of the group handled the recruitment and interviewing, the telerads themselves might have been given differing expectations…and perhaps remember (whether correctly) that they were promised certain things that the group is now failing to deliver.

So, forget about “measure twice, cut once.” Mentally measure 

times to the point that it feels overdone and you’re sick of the exercise. By all means, seriously consider hiring your own telerads. But make sure your considerations go beyond immediate concerns. Really dig in and have a long-term plan, and make sure everybody in your crew participates. Explore every hypothetical you can think of—and try to brainstorm ones you can’t—because what will matter to you tomorrow might not be on your radar today.

Even inquire with some folks currently doing telerad-work (or hire a consulting firm if you’ve got money to burn); pick their brains to see what matters to them, and where they’ve seen other groups stumble. That way, yours might not have to.

Follow Editorial Board member Eric Postal, M.D., on Twitter, 

Think long-term when considering teleradiology hires.

One Size Fits All. And, If You Believe That…

Increasingly many years ago, I was approached by someone from the emergency room. Doctor, noctor, I don’t recall…whoever it was had seen something on a chest X-ray that looked iffy to them, and they wanted me to re-check it. I looked at it again, still saw nothing amiss and said so.

“Well, what’s that,” came the rejoinder, with an accusing finger pointing at some shadow or other on the image.

An uncomfortable feeling came across me, as I could not confidently name an anatomic structure (or confluence thereof) that was responsible. However, I recognized the shadow as something I’d seen on hundreds, if not thousands, of CXRs gone by, and I knew it wasn’t pathology. I said as much, and that was good enough for my visitor. It had to be, since he didn’t have anybody else to ask (and I never heard about it via quality assurance).

 “I’m the expert here, and I say it’s fine,” but that could have been a different way to say the same thing. Sufficiently undiplomatic that I’d never actually utter it—heck, I kind of recoil at the thought of proclaiming myself an expert now. I’ll get back to why in a bit.

Still, “expert” is a reasonable word to apply to anybody competently practicing radiology. Some rads are more expert than others, what with sub-specialty training and years in the field. But compare any one of us to a non-rad, even a physician of another specialty, and we’re experts by comparison.

(Okay, I’ll grant that certain other docs might be better at getting particular bits of info out of imaging pertaining to their sub-specialties. Surgeons looking specifically at things they’re experts at cutting, for instance…but the spine-guy is in for a bad time if he fails to appreciate a renal-cell carcinoma next to the disc he’s sizing up.)

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One of the things about seeking an expert’s opinion is that you generally don’t begin by testing his expertise to see if he’s worthy of your trust. (We’re not talking about a hostile “expert witness” whose credibility you want to tear down—this is someone you’re consulting.) If it’s a given that he’s the expert and you’re not, all you risk doing is wasting time and inserting hostility into the proceedings.

Similarly, the expert generally doesn’t want to begin by proving his expertise to you. Remember, he’s not soliciting for business; you came to him, not the other way around. Coming up with ways to showcase one’s expertise can be perceived as “protesting too much,” sowing seeds of doubt where there were none…and, again, might be seen as an unwanted waste of time.

An attending in my fellowship-program sort of taught this point. He would tell rads-in-training that the purpose of their reports was 

 to teach referrers radiology. For instance, don’t explain all the reasons why an incidental renal lesion is a simple cyst, or how you know the liver is fatty; just state the pathology and move on. His main drive was keeping reports concise—but another worthwhile facet is that the more an expert goes out of the way to explain himself, the more he risks looking like not so much of an expert.

Another mentor, further back in my training, observed that folks’ depth of knowledge is surprisingly shallow. Ask them something about their expertise, they’ll probably know it. Ask them a follow-up about the underpinning stuff, they’ll be reasonably familiar. Go a question or two deeper, they’ll start getting shaky.

They might have known the answers at some point—but after their education, they stopped needing to know that info, and it got buried in the cobwebbed recesses of their memory. Given a chance, they could look it up and re-familiarize themselves…but, much like an adult who gets irritated by a kid who keeps asking them “why” questions on a subject, they won’t look so wise or all-knowing in the process.

 the expert, unnecessarily volunteering to dig deeper into how you know what you do gets you closer to a point where you won’t have answers…and you might just interest your audience enough to ask for them. Why risk that?

Society has generally gotten more weary and less respectful of experts as it is. It seems that every talk show, whether posing as offering “news” rather than opinions, boasts its own experts…helpfully labeled as such at the bottom of the screen and lathered up by the adjacent talking heads (or pilloried if invited on the show as a token of the opposing view, little more than a strawman). Whatever expertise they actually have always seems to take a distant back seat to the axes they’ve got to grind.

Which gets back to that reluctance I’d mentioned above: The last thing I want to do is come right out and hype myself because that’s just an invitation for circumstances to take me down a peg. If I say anything like, “I’m the expert here,” it raises the point for refutation.

I think the better way is to simply demonstrate your expertise. Matter-of-factly, unceremoniously, as if you do it all the time—which, hopefully, you do. Repeated interactions with you will teach others that, yes, you know what you’re doing…especially if you are honest about being beyond your depth on the occasion that it happens.

Quiet, humble, self-assured competence inspires a lot more confidence than tooting your own horn like a snake-oil salesman claiming to have the goods that everybody else needs.

Sometimes letting your work speak for itself is best.

Trust Me, I’m an Expert

One of the fundamental purposes of diagnostic radiology is to differentiate between “normal” and “abnormal.”

Sometimes it’s easy, not even requiring a rad’s skills. For instance, a severely comminuted, mal-aligned fracture on XR: An erstwhile mentor of mine would have called it a “janitorial diagnosis,” meaning that a janitor, sweeping up at the far end of the reading room and glancing up to see the pics, would say, “Yep, that’s broken,” and resume sweeping.

An awful lot of the time, things aren’t so clear-cut. One learns in med school that there’s a 

 of “normal,” and comes to use phrases like “within normal limits” to reference this. Many even memorize certain ranges within their field of expertise. Most rads have a good idea of what constitutes a normal-sized heart on chest X-ray, when to call splenomegaly, renal atrophy, etc.

A preceptor of mine liked to point out the common practice of using bell curves to define normalcy. In the name of diagnosing and classifying things, “normal” is often defined as being within the range of population-mean plus or minus two standard deviations. Majority rules: the central roughly 95 percent of the curve gets called normal, and the top and bottom 2.5-percent tails are “abby-normal.”

It makes a certain amount of sense. If you’re looking at a CT and the spleen is bigger than it is in 97.5 percent of the rest of humanity, there’s a decent chance that something’s amiss. Might it still be normal for the patient? Of course. It 

 be constitutional. If you investigate causes for asymptomatic splenomegaly and come up with nothing, at some point it becomes reasonable to leave it alone. Rather than insist that it’s too big and needs to be hacked out for the pathologist to scrutinize.

Which sometimes flies in the face of what we rads do. If established parameters say that organ X should be no more than 10 cm, and you call 12 cm normal on a scan, be prepared for someone to successfully zing you on quality assessment (QA). Even if you have scans going back 20 years showing it has always been this size, you’re still only safe from QA if you state that, yes, it’s larger than usual, but stable.

The preceptor mentioned above noted the sometimes absurdity of bell-curve thinking. Is it abnormal if someone is more than two standard deviations above the mean for height? IQ? No? Well, then, how about if they’re 

 the mean by more than two standard deviations? There’s a certain value-judgment going on when we decide that being in extreme percentiles at one end of the curve is “good” and the other is “bad.” Even if we substitute clinical-sounding terms like “adaptive” and “maladaptive.”

There’s also the matter of how much the bell curve used for diagnosing someone should be tailored to their particular circumstances. Assessment of height, for instance, is a lot less meaningful if you use a single curve for the entire population as opposed to separate curves taking things like gender and ethnic background into account. Except every time you want a curve correcting for some additional factor, you have to set about gathering and analyzing data for it…and your target-population gets smaller and smaller, diminishing the statistical power of it all.

And yet, each such refinement gets a step closer to something most of us learned in childhood: Everyone is different, and it’s not necessarily accurate or fair to judge them via standards based on others who don’t share those differences.

One might imagine a diagnostic rad, and indeed other professionals (medical or not), would maintain a greater awareness of this than most. We know what happens when wrongly proclaiming or even implying abnormality: Unnecessary further workup, needless treatments, patient worry, and of course dreaded dings to our QA stats.

That awareness goes away entirely too easily when we’re not practicing our profession. Maybe social media deserves some of the blame, but it seems to me that we’re awfully intolerant of variation from our personal norms when we’re not seeing them via PACS. There’s a pervasive “I’m normal/reasonable/right and anybody differing from me isn’t” attitude afoot in society, and rads are not immune:

Someone’s radiology gig differs from your own (tele versus onsite, academic versus private practice, 1099 versus W-2)? They’re wrong. Stupid, lazy, greedy, mercenary, gullible, naïve, selfish, pick your pejorative.

You overhear an exchange of advice between a young rad and a more-seasoned one, or see it in an online forum. The older rad’s experiences, or his interpretation of them, don’t mesh with your own? Or the younger rad’s interests don’t match your values? So easy (and common!) to condemn/dismiss them based on your own subjective reality.

A colleague bought himself a McMansion, a nice boat, or a sports car, while you prefer to live well beneath your means in the name of saving up and future-proofing yourself? What an idiot that guy is, right? Or maybe you’re the one living lavishly, and you see your more-frugal workmate as a pitiable, joyless Scrooge.

Someone strolled out onto the conversational minefield of politics and doesn’t see eye-to-eye with you on the issues? Voted for a candidate/party you didn’t like? How readily people allow a throwaway comment or two to derail relationships that were built up and enjoyed for years and years. It can’t possibly be that they formed their opinions just as reasonably as you did yours, based on different perceptions, values, and previous experiences, can it? Nah, there’s got to be something wrong with them.

My suggestion? Try to remember that “within normal limits” applies to a lot more than you can see on PACS. What might be abnormal or wrong for you might be perfectly reasonable for someone else. Hating and/or lashing out at them, even removing them from your life, might be excessive “otherization” on your part. Or, when they demonstrate their own variability intolerance towards you, a little charitable understanding might help you to not respond in kind. Indeed, your demonstration of greater variability tolerance might just help them rediscover some of their own.

Being outside the standard deviation isn’t always a bad thing.

Eric Postal, MD

Articles

The F-word: Think It, Just Don’t Say It

One Size Fits All. And, If You Believe That…

Trust Me, I’m an Expert

Variability Intolerance