Eric Postal, MD

In the middle of my morning routine this past week, I had a standard interaction with the household pooch. She was sitting nearby, our eyes met, I said something, and she approached with tail wagging to receive some scratches from me. Both of us were gratified for our minimal efforts: Her approach and tail-wagging indicated her appreciation of me, and my verbalization/scratching did the same in reverse.

The thought stuck with me as my workday ensued: We humans don’t show our appreciation for one another all that much, outside of family and friends. Downright miserly with our positive feedback, when it comes to work environments.

It could be that, for most folks, work is a relatively joyless affair. If you’d prefer to be somewhere other than you are, doing something else, it might take all of your motivation just to attend to your responsibilities. There might be little psychic energy left to distribute positivity to those around you. Folks doing what they’re supposed to be? Well, that’s what they’re getting paid for; you’re not wasting your meager reserves to coddle them.

Immersed in a culture of non-appreciation, one adapts. If I find that, day in and day out, I’m getting my job done, and nobody ever says a positive “boo” to me, I’m probably going to return that indifference to everyone with whom I interact. Especially if I think I’ve gone above and beyond—getting more done or doing it with higher quality. If it seems to me I’ve been doing 110 percent and everyone else is in the 90 percent-to-100 percent range, I might go beyond indifference, to resentment.

I also think some folks are wary, consciously or otherwise, of expressing positivity about others in their work environment. Why risk praising a subordinate if you might have to take them down a peg or two later on? And, if you express approval of a peer or a superior, might they take it the wrong way? Who are you, to comment on their performance?

As understandable as all of this might be, it’s maladaptive. In a column of yesteryear, I wrote about the too-often-wrong focus of quality assurance (QA) programs: Detecting, tracking, and remediating errors, but rarely if ever focusing on work that was particularly well done. In psychological terms, business-as-usual QA is “aversive conditioning.” It’s been shown to shape behavior, but not as well as “positive reinforcement.” In other words, catching somebody being good works better than punishing them for being bad.

Being stingy with appreciation risks “negative reinforcement,” which is not the same as aversive conditioning. Negative reinforcement means taking away something desirable in response to unwanted behavior. For instance, withholding an end-of-year bonus from someone who previously got bonused. It shapes behavior most effectively if the reinforced individual knows 

they’re no longer receiving something…but even if no such connection is spelled out to them, they might come to their own conclusions. (“I’ve busted my hump since day one, and nobody seems to notice. Think I’ll take it a bit easier from now on.”)

I’ll emphasize that positive reinforcement does not need to be a big deal: A financial bonus, a promotion, even an “Employee of the Month” certificate…such things can of course be strong motivators…but, much like with my doggo, simple words, even gestures go a long way.

Perfect example: One of the human resources folks in my current rad group takes the opportunity to say something positive in most interactions, even if sometimes in jest. I can’t speak for anybody else there, but to me she’s always a spot of sunshine. Small wonder that she’s usually the point-person for recruitment.

Changing the culture of a group to be freer with verbal encouragement is no small project; heck, even getting one person to alter their behavior can be tough. Leadership and other senior members of the team can make it happen more easily/naturally if they exemplify the proactive-positive approach.

Since I imagine more than a few readers aren’t in such lofty positions to enact change, and might remain relatively starved of positive regard in their workplaces for the visible future, allow me to tell you what you should probably already be hearing. Not all might apply to your particular circumstances…but, when in doubt, be generous to yourself:

Thanks for your part in clearing the worklist every day!

Good job fielding those calls from referrers/techs/patients, answering their questions, addressing their concerns! Always easy to get in touch with you.

Other members of the team really appreciate that you’ve made yourself available for consultations—both in and outside of your subspecialty.

Hey, those are some nice suggestions you’ve made to leadership! It’s great to see interest from members of the team.

Scheduling wants you to know: They really appreciate your flexibility and reliability. You pitch in when they need help with coverage, and never have unexpected absences for them to fill in a hurry.

Thanks for always being on top of your CME and other credentialing requirements!

Just wanted to acknowledge your timely responses to messages and attentiveness when following up on issues. Way too many people respond late or not at all…you could teach them a thing or two.

Great diagnostic catch on that case the other day! A lot of rads would have missed it.

You’ve got a broad comfort-zone with the types of studies you read. “Plug and play” rads like you who can fill just about any spot in the schedule are priceless!

It’s been great having you on the team for [X amount of time]; I hope we continue to make you feel welcome!

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

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Positive acknowledgement can go a long way.

Nicely done!

I’m fond of PET scans. Not just because of the modality’s intrinsic merits; for whatever reason, it seems that most rads in our field find PET beyond their skillset and/or not worthwhile to learn. Being an exception to that rule makes one something of a wizard. I’d be entirely content to log on any given morning and see my worklist chock-full of them.

Only a couple came my way this past week, and one of them stumbled out of the starting-gate: I saw that the same patient had been PET-ed only about a month before. No diagnosed malignancy, just “follow-up” for an active sub-centimeter lung nodule.

Cynical thoughts flew through my mind: How did this re-scan get authorized, so soon after the prior? Who thought this was a good use of resources, not to mention radiation dose to the patient? No way was it getting reimbursed. As the two studies’ data percolated through the software we use for PET, I shot an instant message to a colleague about the matter, and we groused together for a bit.

The studies finished loading, and the nodule was same as it had been…but, hush my mouth, there were now a couple of enlarged/active lymph nodes in the mediastinum. Quite a change, given the short interval. I went from disapproving to mystified: Did the referrer somehow 

 that a rapidly progressing cancer was present? Or had s/he just blundered into identifying significant new pathology earlier than others would have?

As many readers can probably attest, most of the time we receive a “too soon” follow-up exam, it does, indeed, turn out to be too soon for the study to be useful. My most frequent example is pulmonary nodules on regular ole’ CT. A prior study spelled out that the next scan should be in six months, perhaps, or even three…and here we are with a 1-month follow-up. Congratulations, the lesion is stable, but it’s too soon for that to mean anything. What now, O smarter-than-Fleischner referrer?

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The most contentious I ever saw this get was in the hospital where I did my fellowship. Some clinicians there thought nothing of getting daily follow-up CTs for pancreatitis—on a couple of occasions more than once per day. Or machine-gun CTAs: “Is there a pulmonary embolism?” “No.” “Okay, the patient coughed again. How about now?” This sufficiently aggravated the rads that we 

Being the rad sounding the “too soon” alarm isn’t easy. It’s far from a unique circumstance, so you always risk sounding like a broken record. It also can make you look whiny, like a kid who doesn’t want to do his chores…from the perspective of the referrers who are convinced they “need” study X done, or from members of your own team who think they’re telling you something new with statements like “This is a service industry,” and “We have to give the referrers what they want.”

Indeed, without such team members backing you up, any “too soon” protestations you make are wasted breath. Most rads learn this sooner rather than later and wind up just muttering under their breath as they read the meaninglessly stable excess imaging. Or griping to colleagues, as noted above.

Over the years, I’ve heard of patient radiation-dosage tracking initiatives that one might hope would have some sort of impact on this. Clinicians trying to order a patient’s sixth triphasic-contrast CT in a year might, theoretically, encounter some automated pushback. Maybe even get flagged for a talking-to. Somehow, that doesn’t seem to be happening.

I think the strongest antidote for too-soon re-imaging is, like it or not, financial. Pure-capitalist society, 100-percent socialized medicine, or anywhere in between, the equipment, contrast, electricity, and manpower are being paid for somehow. Resources are limited; hence, overuse has consequences.

In other words, whoever’s doing extra work or allocating excess resources but isn’t getting paid for it is going to notice. Human nature being what it is, I suspect they’ll react more strongly to such circumstances than they did when they heard that patients were getting radiated too much.

So maybe the government or insurance companies get more aggressive/creative in finding new excuses to deny authorization for imaging, or retroactively de-authorize studies that have already been done. Whoever’s most directly impacted (collecting the billing) is going to be most likely to seek changes to the situation.

Diagnosing the problem doesn’t seem too hard: The people ordering excess imaging don’t face negative consequences for doing so. About the worst thing they have to deal with is the bureaucratic hassle of getting something approved—and since they can delegate that hassle to others (office-staff), it’s not even a speed-bump to the referrer.

Once their order gets past the authorization-goalie, they never have to worry about it again. At that point, either the hospital or the rads themselves have the joy of trying to collect for the diagnostic work. If the study doesn’t get reimbursed, that’s red ink on the ledger for others, never the referrer.

It seems to me that closing this loop and providing real negative feedback would be the most reliable way of bringing about change. Some sort of referrer-QA system, perhaps, in which repeated offenders could see they were racking up bad stats…enough of which might result in corrective action.

Or maybe just impose a “you partied, you pay” rule: Referrers ordering “too-soon” follow-ups or other unwarranted imaging that doesn’t get reimbursed wind up seeing the negative financial impact imposed on their books, rather than the rads who compliantly did the work that got put in front of them.

By all means, there could be an appeals process so the referrers had a chance to explain why they thought their orders were justified…after all, as evidenced by my PET, sometimes it 

The frustrations and realities of re-imaging orders that come back around quickly.

Too Soon?

I’ll start by saying that I have never so much as touched a surfboard. Haven’t even felt inclined to try standing on one of those super-broad/stable SUP things.

Nevertheless, I’ve got a lifelong appreciation of waves…greatly antedating my physics lectures in radiology residency and pre-med curriculum. Living near beaches and frequenting them every summer, I had plenty of exposure to waves of all shapes and sizes.

The crest of a wave holds my interest the most, and I’m surely far from alone in this. A wave’s got plenty going on elsewhere, but eyes are drawn to the peak. How high will it get? Has it overextended itself; is it about to collapse? Sooner or later it will, of course, as with most things we mortals encounter.

From certain perspectives, however, a wave lasts as long as it needs to (or longer). For instance, during those trips to the beach, I spent plenty of time bodysurfing. Depending on how well I negotiated the crest, I might ride all the way to the sand, the wave might get away and leave me behind to watch it go…or, sometimes, I’d get a little too far forward on the wave, pulled underneath it, and chaotically spun/churned.

No surprise that such a background has predisposed me to regard various ventures as being akin to seeking out, perhaps riding, the crest of a wave.

Case in point: Recently selling my vehicle. Purchased at the end of 2005 and still serviceable but increasingly crying out for replacement, it had surprisingly good retained value according to sources like the Kelley Blue Book (KBB). I knew I didn’t want to just trade it in at the dealership where I was getting my new ride; that’s easiest but also gets you the least. KBB helpfully gives you a range of prices depending on whether you do that, sell to a used-car entity, or (best but requires the most work) sell to another private party.

I decided to go with the middle option. Outfits with names like “CarCash” varied in their offerings, but generally matched what KBB predicted. One stood out with a quote that was solidly in the better, private-party price range.

Too good to be true? Maybe. But I did some digging and confirmed for myself that the outfit was not only legit, it had strong ratings from both previous customers and professional reviewers. Moreover, they were one of the few that would do just about the entire process online, only coming to pick up your vehicle at the end of the transaction.

In other words, they were the crest of the sell-your-car wave, offering the best in terms of both pricing and convenience. I pulled the trigger and successfully completed the transaction within a few weeks. No unpleasant surprises.

How could they do this? Maybe they won’t be able to for long; maybe paying out that much more than their competitors will prove to be a non-viable business model, and their wave will collapse. Or maybe they’ve figured out something that others did not, and they’ll capture a whole lot of market-share…their wave might, thus, crest even higher and more impressive. Whichever: For my purposes, it did exactly what it needed to.

I have a similar story about a computer I bought for myself before my current machine: I identified an outfit that was doing what others were not (offering a website where you used drop-down menus to assemble, piece by piece, various hardware components that would be compatible with one another, with competitive prices for each item you chose, and, then, they’d assemble it). I wound up with a rig that had exactly what I wanted rather than a cookie-cutter Dell or the like.

This doesn’t always work out so wonderfully: Years later, seeking my current computer, the original outfit’s wave had continued to swell mightily, to the point they could demand higher prices and were no longer a bargain. So I tried a relative newcomer to the biz who was doing similar things with a lower price-tag…would up with mediocre results.

A similar approach has served me well in my radiology career, for instance when changing jobs. When I started writing this column, I was making a move from a traditional onsite private-practice group to vRad (vR). Considering the bad job-market at the time, vR’s wave was cresting nicely: They had just become the biggest player in the field. They arguably offered the best suite of hardware, software, and support-personnel to boost their rads’ efficiency and productivity, and that translated to the best professional livelihood I could expect without uprooting my life and relocating.

I leave it to others more recently-familiar with vR (are they ever going to just call themselves RadPartners?) to opine about whether that wave has gone on to further crest or collapse. When it stopped cresting for me, personally, I sought a replacement which would crest in ways vR was not…and am now in my third year with the group that I found.

Rads seek out things like compensation, schedule, reasonable expectations of productivity, etc., and groups do what they can to appeal to such interests. Some groups “reach” further, by claiming to offer what others cannot. If they can deliver and continue to thrive, those groups’ waves crest higher. If they can’t, they risk varying degrees of collapse.

But, there are other ways to crest more impressively than the competition, especially offering things that nobody else has. Sure, it’s nice to boast that you’re paying $2 more per RVU than the next guy…but if you can provide a reliable track to real partnership in an area (like telerad) where others aren’t? Or allow some rads to literally log on and read whenever they like, rather than adhere to a schedule? That’ll make you stand out.

Let others watch and wait to see if you overextended. If you did your homework and formed your plan carefully, by the time they figure out that they need to do what you’ve done, and follow in your footsteps, your wave can already be cresting higher with even newer initiatives.

For radiology practices, paying attention to – and offering to meet – industry needs can help differentiate you from the pack.

Crest of a Wave

I’ve touched on the concept of a troubleshooter in this column, years gone by: A designated member of a team who makes it his business to identify, collect, analyze, and fix problems – sometimes even prevent them.

To date, I don’t think I’ve encountered one, nor recognized evidence of their existence, by the work they’ve done. That’s kind of the point of the role: If there 

 an effective troubleshooter (or more than one, for particularly proactive outfits), someone outside of the organization probably wouldn’t know.

 of troubleshooters, however. You have, too, even if you didn’t recognize it at the time. Such evidence commonly takes the form of fundamental flaws in goods, services, protocols, you name it. The sorts of thing that should have been noticed and corrected before they ever saw implementation. Or, if allowed out the door, targeted for correction as soon as the first user took the trouble to complain. You might have been motivated to exclaim aloud to someone (or yourself), “How can they function like this?” Or, “How can they continue to screw this up after all the times I’ve told them about it?”

Websites with “contact us” links that are seemingly not monitored. Send them whatever messages you like, nobody ever replies. Some organizations can’t even manage it internally: Email other members of your team or another subsection, leave them voicemails…it’s like pulling teeth to get a response.

Sites with search-functions that never return results. I recall, back when I was looking for a new job, I’d see sites that had telerad gigs amongst their offerings. To screen out the onsite jobs of no interest to me, I’d put “teleradiology” in their search-bar. Response: “No results matched your search.”

Various organizations that can’t handle requested changes to contact information. I have a handful of entities that just cannot figure out how to stop calling my cellphone, even though I have told them a gazillion times that I have zero signal at my house. “Just delete the number from your database,” I’ve pleaded/demanded to people who “yes” me to death but, then, do nothing effective. Ultimately, I just changed the “greeting” message on my cellphone’s voicemail to politely tell such callers that they are idiots who can’t follow directions.

And healthcare/radiology are no exceptions:

Rad groups whose techs and/or other behind-the-scenes workers routinely populate worklists with studies that have known priors for comparison—indeed, the “reason for study” specifically states that this is to follow the CT or US of date X—and the prior studies are conspicuously absent.

Facilities which take no corrective action when their sonographers repeatedly upload images without “worksheets” documenting their findings (or specifically stating that they had no real-time impressions of pathology).

Studies somehow making it through the pipeline to reach rads without a single word of clinical history: Forget about doing a decent diagnostic job for the patient and/or referrer, the coders/billers aren’t going to allow those reports to go through.

It’s not surprising that so many of these things go uncorrected. The way things usually are, each little segment of an organization is in charge of its own issues. They’ve all got limited resources and are often overtaxed with other things that, rightly or wrongly, have been given greater priority. Their only consequence for letting this stuff slide is having to deal with more of the same complaints (nagging, perhaps, to their ears)…but eventually the complainers will give up and go away.

The problem with this approach is that customers, and even other members of the team, rapidly get the impression that the organization is sloppy, uncaring, frustrating to deal with, and/or incompetent. And, if it’s incompetent with the little things, can one really have faith that it will be any better with the big issues? Is this a good organization to do business with or work for? Maybe the competition on the other side of town has their act a little more together…

My solution of an appointed Troubleshooter gives these assorted hiccups another path to resolution, one that doesn’t rely on multiple separate sections of the organization policing themselves. Sort of like an internal Grand Inquisitor, the Troubleshooter is known as the person (or team) you go to if you’ve got an issue that just isn’t being resolved. Having taken on a case, the Troubleshooter has authority to demand answers from pretty much anybody, in the name of optimization.

The Troubleshooter collects relevant information from everyone involved: The complainant, whoever the complainant is having issues with, other parties as needed. “We’re working on it” or “We’ll try to do better” are not magical, don’t-bother-us-anymore responses; the Troubleshooter has authority to require a detailed explanation as to how/why the problem hasn’t been solved already. In writing, if necessary.

Having gotten all of the details, the Troubleshooter can, then, analyze the situation and determine:

Whether there is, indeed, a problem that needs solving. If not, the complainant gets an explanation and options for dealing with the situation. After all, there’s a chance that he perceived a problem where there really wasn’t one, or that it would be more efficient for him to modify his approach than to require others to change what works for everyone else.

The simplest, most effective means of solving whatever problems are confirmed to be present. Maybe another option or two to offer to Leadership, so they have a choice.

The Troubleshooter then conducts a follow-up or two with the relevant parties to see how the solution panned out, and determine whether further action is needed/warranted.

A beneficial side-effect: Folks in various segments of the organization would probably rather conduct their own affairs than have someone like the Troubleshooter, however capable they might be, getting involved. Anointing and empowering a Troubleshooter might just inspire them to self-police a little more effectively.

Identifying someone to pinpoint and fix problems could result in a more smoothly run organization.

Eric Postal, MD

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Nicely done!

Too Soon?

Crest of a Wave

The Troubleshooter: Conspicuous If Absent