Eric Postal, MD

A relatively recent comic-strip from Scott Adams, whose work I’ve referenced in the past couple of columns: An office-cubicle dweller complains that his company won’t pay current employees competitively, but hires newbies with better salaries. He’s answered that the company’s budget for recruitment is bigger than the one for retention.

One might divide the professional world (radiological and otherwise) into upper and lower tiers. Upper folks have a seat at the table where the budgets are set and adjusted, and can do so in their own favor. Lower folks abide by the retention-budget where they work…or leverage recruitment-budgets by switching jobs.

My hope has always been to land a good gig. Wow them, earn partnership or its compensation-equivalent, and stay put for the rest of my career. That hasn’t happened. Rather than wring my hands and endure the status quo, I’ve developed a cyclical system of moving onward/upward from dead-end jobs, giving myself a raise each time:

Maybe it’s your very first gig after training, maybe not (remember the system is a cycle, so this might follow phase 4). As a newcomer, you’re watched carefully. So make a great first impression, and give them every reason to believe they made the right decision in hiring you! Turn out better than they could have hoped, such that you prove yourself to be a “sweet deal.”

Make yourself indispensable. Go above and beyond in every way you can—which might be jarring if you’d been relaxing a bit in waning days at your previous job. Be your most professional and collegial self. Constantly be on the lookout for ways you can fulfill as many of your new group’s needs as possible. As with all good systems, this has more than one benefit: In addition to impressing your new team, some of these good habits might just “stick.” You become a better radiologist, and if this group doesn’t ultimately keep you, you’ll bring more to the table when you’re seeking a new gig in phase 4.

Meanwhile, don’t let the post-hiring scrutiny be a one-way street. Keep eyes and ears open for anything not living up to expectation. Of course that includes contractual stuff, but there were surely things said and implied during recruitment/negotiation that didn’t find their way into print. This honeymoon-period might be your best chance to get the group to honor such verbal commitments…if you let stuff slide now, it’ll be much harder to correct later.

Things have settled down. You’ve been accepted as sufficient for your position, and are now just another member of the group. The scrutiny-spotlight has moved on from you, and is now focused on newer members of the team or other things requiring attention. You reach the compensation-ceiling I referenced in last week’s column, or soon will; there’s nothing else coming down the pike to regard with eager anticipation.

There’s also less outreach in your direction: Partners or other senior folks might no longer ask how things are going, your thoughts on the practice, etc. Whether or not such inquiries were ever genuine (as opposed to lip service). Things might still change regarding your role here, but probably not in big ways.

Don’t take this as excuse to halve your efforts. You might not be able to maintain the “look what a great new member of the team I am” pace you did in phase 1…but the more you relax it, the less reason you’re giving the group to let you above your ceiling.

In this phase I constantly reevaluate my situation. I have a mental satisfaction-thermostat. Upper extreme is “This job is a dream come true,” and bottom is “This is a nightmare, I’ve gotta get out.” Everything factors into it: Daily nuisances like software or workflow issues that never seem to get fixed, festering disappointments like “They promised X and it doesn’t look like that’s ever going to happen,” or pleasant surprises like “Wow, these folks didn’t tell me they were going to be so generous with their bonuses.”

Not everything impacting the thermostat is external. In 2011 I was fine with working 7-on, 7-off nightshifts. Enthused, even. A few years later I was glad to get back on days. A couple years after that I was pretty darned sick of having to work every other weekend. It’s not necessarily your job’s fault if you grow dissatisfied with it…be sure you give them a reasonable chance to accommodate your evolving needs.

If my thermostat remains fairly high, this might be the end of my cycle. I might stay in phase 2 forever, effectively having found an exit-ramp for my find-the-best-job system. Almost certainly if the radgroup does something like make me a partner or other equity-shareholder type. But if my thermostat drops sufficiently, it might move me into phase 3.

Phase 3: Late-Stage Job; Eyeballing the Exits

Things haven’t gone so well. Maybe the radgroup hasn’t delivered on its promises. Maybe they turn up their demands and/or cut back rewards. Maybe they develop bad attitudes towards non-partners like me. Or maybe I just happen to hear about other jobs that are offering things mine is not.

 go prowling job-listings until you’re pretty sure this is a dead-end for your career and you need to move on. If there’s even a chance that your dissatisfaction is transient, refrain. Getting that job-hunting ball rolling creates an emotional momentum that can be hard to stop. Once one mentally has a foot out the door, it can become easier to leave than stay…even if that entails trading down.

The opposite is also the case: Don’t wait until you’re perfectly miserable or otherwise in a super-hurry to quit. The search for your next job will be most fruitful if you can do it under your terms, meaning that you don’t have to lunge for the first halfway-decent thing that comes along.

Let your current gig be a comfortable armchair from which you assess your other options; not an ejection-seat from a tailspinning airplane. If you know you can stay put and work more or less comfortably until just the right opportunity comes along, your chances of trading up are far greater than if you’re desperate to move on. In the armchair, you remain open to the possibility that your current gig is still better than anything you can find out there, and thus stay put until/unless that changes.

Soul-search and think about what you really want: Work-schedule, comp based on productivity versus time, onsite vs. remote, subspecialty vs. a more generalized case-mix, etc. Some of your preferences may have changed since you started your current job; take special note of them. Get a feel for which facets trump others, because it’s unlikely you’ll find a “dream job” that has it all. And be sure to include pertinent negatives: Things you’ve encountered in your current gig or priors that you don’t want to see again.

You might be tempted to let the leadership of your current group know that you’re considering moving on, giving them a last chance to fix what’s broken and retain you. I tend not to: At this point, it’s unlikely that they’ll do anything substantially favorable in response to a threat from me. Plus, as long as they don’t know I’m thinking of leaving, I can remain comfortable in my metaphorical armchair for as long as my search takes. Once they do know, they might figure they’ve got no reason to be particularly nice to me anymore, and my current job might get increasingly unpleasant.

Time to trade up! You know what you’ve got, and how it’s fallen short. You know the things you want, and how you’ve prioritized them. You’ve probably glanced at job-listings, even inquired of other rads on social media.

Now it’s time to pull out all the stops and routinely check in with every source you can think of. Cast a wide net so you don’t miss anything. I use half a dozen websites for my “rounds,” and check them every single day when I’m on the hunt. Twice, actually, since I noticed that there seem to be certain hours when a lot of recruiters post their wares. Some sites’ filters and sorting-tools are less-than, so I regularly do a general search and then a second for my interests (teleradiology for instance). I sort by recency.

With this system of daily or twice-daily checking, I immediately see what’s new since I last looked. I come to know the verbiage associated with certain jobs, even if they update their listings now and them. And I get familiar with the import of things 

Another important feature of looking frequently: If a particularly good opportunity turns up, you want to respond to it ASAP...because a bunch of other people will, too. Try to be one of the first rads they consider, since they might get overwhelmed and less “hungry” for later applications. Or stop responding to job-seekers entirely.

As your search goes on, take note of what’s being offered out there—even by jobs that you’ve ruled out for one reason or another. Develop a sense of the marketplace, and adjust your expectations. You might find you were expecting too much (or too little). You might yet discover that your current gig is pretty darned good by comparison—enough to push you back into phase 3 for awhile.

If you’re still in your comfortable armchair at this point, hunt as long as you can. Don’t let amazing opportunities go by, but also don’t prematurely apply and interview for gigs failing to stand out from the rest in terms of how they match your wants/needs. Take a long time aiming at prospective targets before you pull any triggers.

When you do, if at all possible aim for 2 or 3 at once; I found it surprisingly frequent that when I got one “hit,” others surfaced in my daily searches along with it. Even if one stands out above all others, it can be worthwhile to go for the second- and maybe even third-best options you’ve found recently. You can thus change the power-dynamic in your mind: It’s no longer you competing with an unknown number of other applicants for a single job, now it can be the 

You can even leverage one against the others when it comes to negotiating deals: “Gosh, I really like the opportunity you’re offering, but this other job I’m considering is offering similar comp with fewer nights/weekends—do you think you’d be able to reduce those?” “They’re willing to let me work from home 2 days per week; would you really need me onsite every day?” “They’re can have me 1099 or W-2; do you offer that flexibility?”

A proficient liar might be able to say exactly the same sorts of thing without having an alternative job lined up—but I suggest sticking with the truth. It’s simpler, no risk of contradicting your own story later on, some folks might detect it if you BS them…and really, do you want to chase away the best job you’ve actually found in favor of one you just made up? Remember, this is a chance for you to find a “rest of my career” job that will be your exit-ramp from this cycle.

One last word, speaking of cycles: No good system exists in a vacuum. The job-market has its own cyclical motion, and you should adjust your approach to it. Trading up is going to be a lot easier if groups are hungry for rads—especially if you got your current gig when the market was grim and they didn’t have to give you very much. If the market gets tighter, try to prolong your stay in phases 2 and 3.

Articles

A four-phase approach to moving onward and upward in your career. 

Give Yourself a Raise: Goals and Systems in Your Radiology Career, Part 3

Last time around, I shared a philosophy for achievement that I’ve pretty much always instinctively lived by, but had been nicely described by author/cartoonist/podcaster Scott Adams: Goals are for losers, systems are for winners.

I can’t think of any area where it doesn’t apply. Being a radiologist and writing this column in a blog on 

, of course, I turned the focus to our corner of the professional/healthcare world.

Now, I’m going to narrow it further, to the matter of giving yourself a raise. More specifically, how I’ve given one to myself a few times, since I think my situation is hardly unique. You may see some parallels in your own situation, and thus borrow from (or improve on) my experiences.

Long-term readers of this column may already be familiar with the different phases of my career. Otherwise, a glance at my CV would tell you that I’ve worked in 4 different rad groups since my fellowship in 2005. Seeing that many gig-switches in a 16-17 year interval might strike some as a warning-sign. Especially back when it was the rule rather than the exception that a decent rad would complete training, join a practice, prove himself to the group’s satisfaction, and thus earn partnership or other such equity.

To the folks who protest that last statement: No, I’m not saying real partnerships are extinct. They do exist in some places, just not where I’ve lived or plan to. One makes one’s choices and lives with them; I chose not to relocate.

If you’re a non-partner employee/contractor, you’re probably on the unfavorable side of a rad group’s compensation system. Yes, they have systems in place, which is why you should too!

With non-per-click systems, you come onboard working for a set salary or hourly rate. If you perform well and stick around, you get a raise after your first year, maybe your second and/or third. But at some point, you max out. (And if you’re per-click, you max out the moment you attain your personal-best rate of productivity.) Ask for more and you’re told things like “you’re at the top of our pay scale,” or that you’re already making almost as much as some partners.

That’s the crux of such systems: To keep partners/shareholders on a level above everyone else. Which isn’t inherently evil; it’s a big piece of the reason why people want to become such insiders.

The system lets those insiders tap into the group’s overall success. They share its upside (just like they share the risk of downside in bad times). Unlike an employee/contractor whose comp has a ceiling, theirs can theoretically increase forever—indeed, automatically will as long as the group grows and thrives.

Sure, a non-partner can still ask for raises after hitting his ceiling, especially if the group is visibly doing well…but there’s only so often one can make such inquiries, whereas the partners have a limitless ability to say “no.” Whether or not coupled with reasonable-sounding excuses. And, if they ever say “yes,” any increase they permit will be a healthy amount below what they retain for themselves.

If there’s no likelihood that you’re going to get inside that system, such that you grow along with the practice (reliable annual bonuses, for instance), your only forthcoming raise may be one you give yourself: Leave to join another group that treats you better.

Even if you just switch to another group where you’ll be up against a new comp-ceiling in a year or three, if that group starts you at or above where you are now, all your bank account knows is that you’re getting above the ceiling that was previously trapping you. Plus, your new group may appreciate what you bring to the table more than your previous one did…to the point that they find a way 

This is exactly what I’ve done, each time I changed jobs. Each new gig paid me more than the previous, and each time there was at least lip-service given to other upsides such as moving up a hierarchy. That even included an offer of partnership in my second post-fellowship job, although longer-term readers may recall the “partnership” was a sham, prompting me to move on.

Another type of “raise” that can be of interest, and you should always keep in mind: Not everything is monetary. A new gig might pay you the same or even slightly less than you’re getting now, but with quality-of-life improvements to the schedule (an 8-hour day instead of 9, no nights/weekends, etc.). Your new digs might let you do more of the type of work you want, and less of what you don’t. Perhaps they promise to make you Section Chief after a trial-period; even if you don’t climb their hierarchy any further, such a title will enhance your CV for the rest of your career.

How can it be possible to keep meriting better deals—financial or otherwise—from new employers? Most important is another system I’ve utilized, and recommend: Always be improving yourself over the course of your career. The rad you are when you apply for your next job should be more competitive than you were when you got your current gig. That can mean reading faster or more accurately (ideally with documentation to prove it). It can mean reading more types of imaging-studies, or doing hands-on procedures. Or taking on non-clinical roles of which you can later boast: Sitting on the QA committee, helping with recruitment, etc.

As with all good systems, your potential gains are not solely from future employers: Increasing your value might just convince your current group to give you a raise or higher ranking after all. Not to mention the “payout” of simply making your work more multifaceted and intellectually satisfying to you.

Another facet of most systems is that they aren’t a one-and-done kind of affair. Their utility is cyclical; each iteration can build on the last, or fill in spots that previous rounds missed. In next week’s finale to this mini-series of columns, I’ll outline the cycle that has steadily helped me move onward and upward in my career, with (and without) the help of my four employers.

Always be improving yourself over the course of your career. The rad you are when you apply for your next job should be more competitive than you were when you got your current gig. 

Give Yourself a Raise: Goals and Systems in Your Radiology Career, Part 2

In previous columns, I’ve referenced the adaptive value of prioritizing systems over goals. The concept is far from new to me; I think I’ve always instinctively lived that way. As with so many things, however, hearing it verbalized by someone else crystallized it for recognition by my conscious mind.

That someone is Scott Adams. He’s fleshed out the idea in a couple of his books (notably 

How to Fail at Almost Everything and Still Win Big

), but offers a pithy challenge/summary: Goals are for losers, systems are for winners.

This can seem like a slap in the face. An awful lot of conventional wisdom out there urges us to set goals, so we’ll have things to work towards. We’re pretty thoroughly indoctrinated with goal-setting before we finish our first decade of life.

A slightly longer-winded explanation he offers: “Goal-oriented people exist in a state of continuous pre-success failure at best, and permanent failure at worst if things never work out. Systems people succeed every time they apply their systems, in the sense that they did what they intended to do.”

For instance, let’s say you’re in the common position of wanting to lose weight. The scale says you currently weigh X, and you set a goal of weighing X minus 20. Maybe you give yourself a deadline: Gotta do it by swimsuit-season.

The problem: No matter what you do, until you cross the finishing-line and the scale confirms you are now X-20, you’re in that state of failure mentioned above, “pre-success” or otherwise. Doesn’t feel good. Can actually drain your motivation. And, if you set a deadline, each day that brings it closer intensifies those unhelpful sentiments.

Further, suppose you do manage to achieve your goal. Hurrah, you high-five yourself and scratch that item off your mental to-do list. No longer pursuing that goal, you might not maintain the behaviors that brought you to it. What happens? A few months later, you’ve regained the weight, which feels an awful lot like failure.

More adaptive is to focus not on the finishing-line of that goal, but a course you can chart that will take you in that direction. A system that, if adhered to, will achieve what you want or a good measure of it. You know that losing weight can result from burning more calories than you consume, getting sufficient sleep, etc.

So you incorporate such measures into your daily routine. That feeling of success, of “I can do this,” is no longer reserved for getting on the scale and seeing that magical number. Now, you can feel it whenever you do your daily exercise-routine, eat a non-overindulgent meal, get to bed on time, etc. Those little tastes of success feel good and help you stay on track…even after swimsuit season has come and gone.

And if you have a lapse? Miss some or even all of your regimen one day? That’s just one iteration of your system; it doesn’t leave you feeling like the whole thing has collapsed. It might even motivate you that much more strongly to get back on the horse the next day.

Another Adams quote: “A goal gives you one way to win, whereas a system can surface lots of winning paths, some of which you never could have imagined.” Suppose you get to swimsuit-season and your scale still shows a higher number than you’d like…but you look in the mirror, and realize that your system/regimen has redistributed your weight such that you look and feel better than you’d have thought possible. Not to mention the other benefits of getting more sleep, eating healthier, etc.

The lowest common denominator of most effective systems I can think of: Identify what works, and what detracts. Do more of the former, and avoid the latter. An iteration of a good system incrementally brings you closer to the things you want (even if you don’t initially recognize them), and keeps the things you don’t further at bay.

Good systems are, in effect, a personal (or team-based), super-accelerated form of evolution. “Survival of the fittest” behaviors to get you ahead…of where you were before, or relative to competitors.

So, how does this circle back to your radiology career? Really, how could it not?

Don’t, for instance, adopt the “goal” of zero misses on QA…because, if you do, every time somebody takes a shot at you, however petty, your failure-alarm will go off. Your only sense of success would be a pristine record each month/quarter/year. As bad as setting goals can be, making any of yours synonymous with perfection is downright toxic: All it takes is one bad moment to render you imperfect, and thus a failure.

Instead, develop systems of minimizing your “misses.” That includes honing your accuracy, but it can also mean learning turns of phrase that render your reports more difficult targets for nitpickers to play “gotcha.” And learning how to effectively defend yourself when disputing a case for the QA-committee.

Setting goals for productivity can also be a bad move. If you determine a need to read X number of cases, you’re living in failure until you hit that X. Worse, if you’ve divided your time by X to see how many minutes you have per case to remain on-target, you have that many more episodes of potential failure each hour.

Instead, develop a system that optimizes your performance. Find PACS hanging-protocols that best suit your style. Develop dictation-macros that speed your reporting. Keep your most-frequently used references bookmarked for easy access. And get disciplined with your work-cadence: Minimize avoidable interruptions, including self-inflicted ones like checking stocks, social media, etc.

And yes, this column’s title did mention giving yourself a raise in the context of all of this…I’ll be delving into that next week.

Focus not on the finishing line, but on the course you can chart that will take you in that direction.

Give Yourself a Raise: Goals and Systems in Your Radiology Career, Part 1

A couple years ago, I borrowed from Glengarry Glen Ross when I wrote about how one should ABR (Always Be Recruiting). More important is ABL, spelled out in today’s title.

The principle would be one of health care’s Ten Commandments, if we had any. Should probably make the top three. There are rules/regs aplenty regarding CME to keep docs walking the walk. Even without those, medicine practically forces us to keep current as new developments constantly bombard us from all sides. It would be difficult not to learn.

So we pick up pearls of wisdom here and there. Some fill in gaps from our education and training. Others are more advanced: A weirdo lesion crosses our path, and we have to figure out what we’re looking at from reference-sources or charitable colleagues. Presto, we have our answer (or a reasonable differential), and now we’ve learned what to say if we ever see the lesion again.

There’s a lot of other potential learning that’s more easily missed. Stuff that doesn’t directly show up on diagnostic imaging or reports of same, and it has no CME. The biggest obstacle to this learning is failure to recognize opportunities for it. Sometimes, even when we think we’re learning something…it’s the wrong stuff.

The tricky part is that the best learning opportunities arise in situations of adversity, when you’re most likely to be distracted. Think about it: When everything’s hunky-dory, what’re you liable to learn? Keep on doing whatever you have been, since the status quo is exactly as you’d wish? Big whoop. No, it’s in circumstances most undesirable to you when you have the greatest room for improvement.

Take, for instance, the situation which inspired my blog from two weeks ago: Malicious hacking took down my rad group’s electronic infrastructure. Teleradiologists such as myself were suddenly unable to work offsite. No work equals no income, which resulted in a decidedly uncomfortable situation for everyone involved.

Visited with such misfortune, folks commonly learn the wrong lessons: “Life’s not fair,” “We make our plans and God laughs at them,” “You can’t count on anybody else,” “Bad luck happens,” “I probably don’t deserve any better,” etc.

Unfortunate truths? Maybe…but they don’t help you improve things, this time around or the next. And let’s face it, by the time you’re an adult, you’ve long since learned such “lessons” time and again. Repetitively self-flagellating with them doesn’t yield new wisdom. It might, however, prevent you from learning new, useful stuff.

Preoccupied by wallowing in self-pity or bitterness at the cold, cruel world, you’re not in the right frame of mind to adapt and overcome. It would be better to recognize what you might have done to defend yourself, what you can do now in the name of damage control, and even hidden opportunities that this turn of events might be presenting you so you can turn your situational lemons into lemonade.

This isn’t always about personal catastrophe or life-altering epiphany. Even the smallest annoyances can provide useful lessons if you’re paying attention. Consider, for instance, a “ding” to your QA. Irksome to the best of us. Sure, some of the time you’re genuinely learning from a mistake you made…but then there are those times where all you’re learning is “I hate QA,” “Dr. So-and-so is a nitpicker,” “This rad group’s process for adjudicating QA stinks,” etc.

Again, hardly adaptive/useful learning. But what if you take the opportunity to scrutinize the petty ways that QA system gets at you? Learn different turns of phrase to use in your reports so Dr. So-n-so has fewer opportunities to play “gotcha.” Take note of how the QA system fails to live up to its purpose. Maybe develop yourself as an expert in QA so you can administrate a superior model. Next thing you know, that’s a highlight on your CV that opens doors for you which would be closed to garden-variety film readers.

One of the most valuable things I learned from my current hacker-induced situation regarded a couple types of insurance (that I wish I had, and that I am now getting): “Business interruption” and “cyber” policies. Pretty straightforward—if your business gets disrupted, such a policy steps in and covers your lost revenue, potentially other things.

Straightforward, yes…but heretofore unknown to me. I’ve been mingling with other rads for over 20 years and not a single one ever said anything about it. (And shame on the various financial and insurance people who have been in my life to never have brought it up! Look how much premium-money they left on the table.)

Knowing of such things, what rad group wouldn’t be insured to protect itself from such circumstances? It wouldn’t be unreasonable for rads in the group to ask that their contracts specify a portion of such insurance-payouts be earmarked to safeguard their income. One might even argue that a group valuing its members should do so without being contractually obligated, but your mileage may vary.

Alternatively, a rad might just get his own coverage. My quick inquiry turned up a quote of under $2k for conjoined interruption/cyber policies…same ballpark as what I pay for disability insurance. An employer might be willing to simply add such a sum to your comp—paying for your coverage rather than committing to shield you with its own policy. And if one employer is willing to do absolutely nothing in this regard—well, others might do better, and more competitively attract rads as a result.

Did I spend time feeling sore about my situation before I learned about, and pursued my own, business-interruption and cyber policies? Sure; it’s only natural to have an emotional reaction when things don’t go your way. But I don’t let it paralyze me. Let it have its moment, then move on. Or, better yet, harness it—turn frustration/anger at misfortune into a drive to learn from it and take action.

It would be ideal to take stock of one’s most-used unhelpful “lessons.” Assemble them into a mental rogues’ gallery. Then, when one or more of them gets triggered by adversity, let it serve as an alarm clock: Wake up! There’s something good to be learned here, don’t miss it!

The tricky part is that the best learning opportunities arise in situations of adversity, when you’re most likely to be distracted.

Always Be Learning (the right stuff) 

Radiology has its ghosts. There’s ghosting-artifact (most commonly in MR, but the term has been used in other modalities). Ghost-reading: Someone without credentials or even a local license provides a low-cost interpretation, and then a legit rad signs that report with his own name. Plus various imaging-findings that got the word attached to them (“ghost meniscus,” “ghost vertebra,” etc.).

All of which might be interesting things, but not my focus today. Instead, another term that’s not specific to our field, but can be highly relevant: The social phenomenon of “ghosting.”

Most of us are familiar with the concept, even if we don’t know it by that name. I only learned this bit of slang a few years ago. It wouldn’t be the first time I’ve emerged from under a rock to join the rest of vernacular-society, but perhaps this column will serve to do the same for a few readers out there who are as unhip as I.

Ghosting refers to unilaterally ceasing communication with someone. Passively, without warning or declaration of intent. You just stop taking their calls, responding to messages, etc. You effectively become a ghost of the person they thought they had a relationship with. Most probably first experience this behavior during the breakup of a romance.

If you’re doing the ghosting, you might see nothing wrong with it. Or you feel some measure of guilt, like telling a “white lie.” Yes, maybe it would be nobler of you to stand up and tell the other party why you’re parting ways…but your reasons could be perceived as hurtful, might even spark a confrontation with worse consequences. Better to take the path of least resistance and hope they get the hint or have enough other stuff going on that they’ll hardly notice your absence.

Being ghosted, on the other hand, doesn’t leave you with much sympathy for your ghoster. Don’t they owe you more than that? Some measure of respect, an understanding of what you did (or didn’t do)? Or at least an “It’s not you, it’s me” story so you don’t indefinitely question yourself over the matter? It can be downright infuriating: They snuck away like a thief in the night, too lazy to give you the closure you deserved.

Folks might get introduced to ghosting during awkward breakups in gradeschool, but the practice of quietly retreating from an unwanted relationship is far more widespread. Healthcare included, despite what one might have hoped for regarding the behavior of “professionals.” Small wonder that the radiologist, a common poster-child for social ineptitude or avoidance, is no exception.

You might experience ghosting, for instance, if you’re supposedly in a partnership-track and ask about your status…but the current partners don’t intend to make you one (if they ever did). If the raise or end-of-year bonus you expected has failed to materialize. You might be ghosted by someone who’s not completing a task for you—a shared project, something you delegated, or even something you requested of a superior. Heck, you could be the one who completed the task, and whoever asked it of you might avoid responding because they don’t want to deal with the results.

You can be ghosted by folks with whom you have the most tenuous of connections; as long as there is a reasonable expectation of response, there’s the opportunity to ghost. I’ve previously written of the unfortunate prevalence of ghosting in the radiology-recruitment world: An awful lot of would-be employers fail to answer inquiries, leaving job-seekers in the dark about what happened to their applications: Being considered? Rejected? Lost in the ether?

Being ghosted professionally can be tougher to deal with than personally. At least with a vanishing social contact, you can work through your side of things and eventually shrug it off. Not so much if the individual ghosting you has something you want/need, or, worse, is someone you still have to work with; every time you see the perpetrator, it’s an annoying reminder. Especially if the ghost ever requests something of you.

Something I’ve come to understand in the fullness of time: Chase as few of those ghosts as you possibly can. It’s a waste of your time and energy, and even if you catch them it probably won’t be worthwhile. They’re scared of confronting you; in addition to whatever they originally didn’t want to discuss, if they face you now they do so as a coward. If you do wind up interacting, avoid referencing their ghosting-behavior (tempting as it may be to watch ‘em squirm more).

A ghost has tried in a very passive way to tell you “no” without actually saying the word. Trying to pry out a “yes” won’t generally get you what you want; they might speak affirmatively but their subsequent actions will rarely live up to it. They’ll do a halfhearted job if they do it at all. They might even resent you for cornering them, and find ways to punish you for it.

Accepting the unspoken “no” doesn’t get rid of all ghosts. Some come back to haunt you. Maybe testing the waters to see if they can continue the relationship without having to address whatever issue they were trying to avoid. Or maybe they just like playing head-games. I’d suggest keeping such folks at arm’s length; if they were comfortable ghosting you once, they’ll surely do it again. Why give them another chance to let you down?

 need that ghost to finish what it started, or you know that nobody else would fill its shoes as well. I’ve had success offering “bait” to come back. A useful bit of information, or some assistance I can provide. The sort of thing I can hold off on delivering, or parcel out, such that the ghost won’t get what it wants until it’s given me what I need. Not a maneuver you want to overuse: There are multiple ways it can go awry, and once a ghost learns you’ve got such tricks up your sleeve, it can become very circumspect about your offerings…or extra-clever about getting them without giving anything in return.

Chase as few of those ghosts as you can in an effort to save your time and energy.

Ghosts in Radiology

A couple Thursdays ago, I got an early-morning call from my radgroup: Don’t bother trying to log in for work, that day or indeed the next few. A nasty bit of hacking had occurred, and taken their entire computer-system down.

Working via teleradiology since 2011, and in facilities large and small before that, I’m no stranger to outages. Sometimes they’re a welcome break…especially if you’re salaried and getting paid the same whether you’re working all day or twiddling your thumbs. Not as much if you know that imaging-cases are still accumulating, and you’ll be frantically trying to catch up when your access to them is restored. 

 not if you’re “per click,” earning zippity-doo-dah while your employer pulls itself together.

Unlike other outages I’d seen, this one wasn’t over in a matter of hours, or even a couple of days. I still don’t know all the details; one of the other telerads theorized that it was on the level of ransomware/cyberterrorism, such that Federal entities were involved. Everything was down, even the group’s websites and email systems, and there was nary a guesstimate as to when we’d be back on our feet.

So far beyond the realm of anything that might have been planned for, this was tantamount to a “black swan” event for the group. I’ve referenced the term in this column before, and there’s a worthwhile book on the subject (“The Black Swan: The Impact of the Highly Improbable,” by Nassim Nicholas Taleb). I won’t rehash it here.

Just because you can’t predict such things, doesn’t mean you won’t have to deal with them if they happen. And even though you can’t thoroughly plan for the unknown (or it would be prohibitively costly to protect yourself against everything that’s less than 0.001% likely to ever occur), there are some things that can make you more resilient for when it comes busting down your door.

Developing and maintaining plans for more probable/predictable incidents is a good start. Some components of those plans might be useful when a “black swan” turns up. For instance, a contingency strategy dealing with more typical, briefer outages might provide a framework for when hackers hold your system hostage or terrorists detonate an EMP in the area. It’s a lot easier to modify a partially-relevant plan for your current situation than to create one from scratch.

Even if none of the plans you’ve formulated can be adapted, devising them in the first place has you in a better place than if you hadn’t. You (and, hopefully, your team) have already gone through the exercise of thinking about the various components that make your operation work, and what happens if one or more of them are taken out. What it might take to function in their absence, if any substitutes can be used, who to call for repairs/replacements, etc. The basic process of methodically sizing up a bad situation will come a lot more readily to you if you’re done it before.

Still, by its very nature a “black swan” event isn’t tidily handled by preparation. The best means of dealing with it is being ready to take, and roll with, its punches. Rather than panicking and going to pieces, you take stock of your troubles and what’s still intact. Then, you have an idea of what stands between your current situation and normalcy, and can start figuring how to get from hither to yon.

Facets of this need not be complex puzzles or massive undertakings. For instance, my radgroup’s usual means of communication (email and instant-message app) were down. Reestablishing contact began with simple phone-calls, followed by external email accounts. Those wanting to keep personal e-ddresses out of the mix simply created new Gmails for the purpose. Group-messages could then be used to relay marching orders and share updates as new information became available (also for offsite rads like myself to post questions).

Another important aspect of being able to roll with the punches is having flexibility and redundancy in your setup. If, under even the best of circumstances, your operation is stretched to its limit or liable to unravel if one tiny component falls out of place, it won’t take a black swan to create havoc…but such an event will be all the more devastating when it happens.

More robust by far is an organization whose members’ roles overlap. If one or more are taken out of commission for any reason (illness, equipment failure, whatever), others might have to stretch in compensation but the net is more capable of holding the burden than tearing under it. And if members of the team are used to having Operations “call an audible” to redirect their efforts when circumstances warrant, they’ll be that much more capable of shifting focus in times of crisis.

Individual members of the team can also make themselves more resilient for when black swans come a-calling. In a lot of ways, similar to the organizational-level stuff: Don’t panic, be ready to adapt as situations arise, etc. That’s especially important for per-click rads who might be facing a sudden cutoff of income for the duration of an outage. Having emergency funds in reserve, for instance, instead of living paycheck-to-paycheck. Some might even maintain separate sources of income, such as contacts with locums agencies.

Simply keeping an adaptive frame of mind can go a long way: Sure, it might be worrisome when your employer is down for the count and you don’t know when they’ll be back up. Maybe you nervously eyeball job-listings, just in case…but, in the meantime, you’ve suddenly got an unexpected bit of vacation. Even if it’s unpaid, try to make use and/or enjoyment of it. Sleep in, jumpstart your fitness regimen, get that stuff done around the house you’ve been putting off, meet up with some friends you haven’t seen.

That visit from the black swan, played the right way, might ultimately turn out to be something you look back on and realize you desperately needed.

Even though you can’t thoroughly plan for the unknown, there are some things that can make you more resilient for when it comes busting down your door.

Things Unforeseen

Last time around, I dwelled on the so-called “pay per click” model of radiology-compensation. As then mentioned, I’ve seen some love it, some loathe it, and a lot of folks scattered across the spectrum in-between.

Most of the non-polar sentiments include a recognition of tradeoffs: Yes, it can be a bean-counting, headache-making, quarrel-inducing mess, but what else are you going to do? Just pay people a set amount and hope they’ll do a reasonable amount of work? Not noticing/caring if they seem to be pulling harder than others on the team who earn just as much, if not more?

A “happy medium” system would be one in which rads knew they could go about their work without fretting over the daily vagaries of their RVU tally…but nevertheless assured that their productivity would be on the record. And that slackers on the team wouldn’t go undetected.

Leadership would, similarly, have an idea who was shouldering how much of the group’s burden…without having to constantly tinker with complex schemes of differing exam-values, deterrence-mechanisms for “cherrypicking” of easier or higher-value cases, etc.

Tracking RVUs, or even RVU-related “work units,” doesn’t really get at this. You certainly wind up with a bunch of numbers to apply to your rads, numbers which can be put on tables and charts for periodic review. You can make sophisticated-looking curves to show a rad’s productivity over time, and stack them up against other rads, throw in standard-deviation ranges, etc.

Most rads who’ve been working more than a little while have seen their performance tracked. Even if you’re not in a pay-per-click situation, the folks in charge need to know if you’ve been generating enough revenue to warrant whatever salary or hourly rate you receive. Also how to fairly apportion bonuses and consider requests for raises.

But as long as all of that is based on curves, bar-charts, etc. derived from your RVU total, the per-click issues are a big part of the picture. Somewhat paradoxically, I think adding a 

 curve would simplify things, for groups preferring to operate via salaries or hourly rates:

By all means, keep tracking RVUs. After all, if that’s how your group is receiving its revenue, it doesn’t make sense to pretend otherwise. Rads who are doing the heavy lifting to make that revenue happen should definitely be recognized, if not rewarded.

But alongside the RVU curve, have another measurement, truer to the simplicity that “per click” implies: A curve of the raw number of exams a rad has read.

This way, the rad(s) who are dealing with the neverending onslaught of low-paying studies like XR…work that has to get done one way or another…can be tracked for the service they are providing. One important facet of which is running interference so the RVU-sluggers can focus on their MR.

Maybe the rads who would look better on the second curve don’t have the skills to read many of the higher-ticket scans. Maybe they prefer lower-tech modalities. Or maybe their other responsibilities (fluoro, diagnostic mammos, fielding phone calls, etc.) interrupt them so much, it’s just easier to squeeze “bite-sized” studies like XR in between.

If such rads know that they will be valued for taking care of the mountain of XR—despite that mountain’s reimbursement-worth being unimpressive next to a reasonable daily haul of MR and CT—they can go about their work without constantly being tempted to sift through the list for brainscans to shore up their RVU-numbers.

When it’s time for performance reviews, each rad’s two curves can then be seen as equally-important parts of the big picture. Total exams in bottom quartile, but you’re tops RVU-wise? You did your part. RVUs low, but study-volume high? You get praise, not browbeating.

Sort of like being on a track-n-field team: A sprinter is used/valued for what he can do in the 100-meter dash. A distance-runner is regarded for his performance in the 5k. You wouldn’t put either guy in the other’s event and expect good results.

Of course, rads aren’t quite as pigeonholed as all that. Some might do well if told, each day they came into work, whether they should be going for case-volume or RVUs. Or self-select which suits them at any given moment, depending on their mood or circumstances around them.

Obviously, not everybody can be focused on the same curve; the work all needs to be done. Some coordination of efforts via assignment of roles might be needed to avoid all the XR getting gobbled up early in the day, lest there be dozens of RVU-heavy scans that only a fraction of the group can take care of. Or the opposite: Nothing but XR left on the lists at 4pm, and while some of the volume-centric rads industriously plug away, the “I wish I had some MR” rads reluctantly poke through a few cases at a snail’s pace.

 of a rad’s curves are relevant, rather than just choosing one to be his personal yardstick. A top-quartile RVU-rad with bottom-quartile volume, for instance, might be considered as being on the same level as a top-volume/bottom-RVU member of the team…as well as a rad who’s dead-center for both RVU and case-number.

Meanwhile, a rad in the 75th percentile on both of his curves might be considered something of a hero, and bonused appropriately. And a rad whose two curves were in the bottom 10% might be approached for remediation…unless, of course, that rad had other roles of value such as in administration.

Because not everything shows up on curves, no matter how many you’re willing to draw.

Clicks and Curves

I never really liked the expression, “pay per click,” as used in radiology. It makes perfect sense in other venues, like advertising. There, a bit of revenue is generated for every click the ads receive. I don’t know the fine details, but imagine things are pretty constant; click equals $X.

In our line of work, that’s not the case…or, if it is in some practices, I’ve never seen it. The closest thing that happens is in “eat what you kill” or other such productivity-based models, where a rad’s comp increases each time he clicks to sign a report. Or uses a click-equivalent to sign off, such as a voice-command.

The issue I have with that? Long before a rad gets to that point, s/he’s clicked more than a few times: To open the case, to manipulate images, to sift through prior reports, to move around in and edit the dictation, sometimes to communicate with referrers and support-staff. It’s really “pay per click

And that’s a best-case scenario: Far from rarely, a rad will open a case and do more than a little bit of clicking around before realizing that the case can’t be read as-is. Images, priors, or history missing, the case needs to be read by someone else, or the rad just gets interrupted and someone else takes the case while s/he’s away. 

 pay-per-click going on there. Also none for clicking when a rad has to revisit a signed report for addenda, questions from clinicians, etc.

Then, there’s the little matter of different cases not having the same worth: Even if it were truly pay-per-click, clicks for XR, CT, MR, etc. understandably pay different amounts. And if you really want to get into the weeds, a given study-type will vary in its yield depending on where the patient got imaged, what payor is involved…

That doesn’t stop some radgroups from trying to bean-count and assign case-values (“work units,” for instance) for the reading rads, of course. They might simplify, and use the average value of a given case-type that the group sees from all its sources. Both for simplicity, and so the rads don’t go nuts lest they see that the chest-CT they got to read is worth less than a chest on the worklist right next to it.

Having been on the receiving-end of this for a chunk of my career, I can tell you that the values never seem to perfectly reflect the time/work balance. For instance, a conscientiously-reading rad who winds up with mostly XR on his list, even if reading efficiently and taking minimal breaks, really can’t keep work-unit pace with one who got a bunch of MR. Even if the MR-rad is far more leisurely.

That’s not all to be blamed on the radgroups in which this happens. Some give everybody access to the same worklists, instituting workflow-rules meant to curb “cherrypicking.” The idea being that, if all rads in the fullness of time get access to roughly the same case-mix, everyone will be hurt by XR and helped by MR equally.

Still, people find ways to game systems, and docs tend to be a smart bunch. If there’s a trick, they’ll find it sooner or later. Also, if the folks making the rules are reading cases like everyone else, whatever rules they make will tend to favor themselves; that’s just human nature.

Another factor: Not every rad has the same skillset. Some might appropriately beg off higher-value exams like MSK MR simply because they know they wouldn’t do a good job. Some older rads might never have gotten comfortable with 

MR. Of course, nobody’s stopping them from learning something new…but not everybody’s going to do that, especially later in their careers. Finally, sometimes subspecialty reads are requested/needed, so certain high-value exams aren’t accessible to everyone.

Another lever some radgroups can adjust is boosting the value of cheaper exams, so rads receiving more of them won’t be at such a disadvantage. Groups can finagle a little bit, robbing Peter-MR to pay Paul-XR…but that can be tricky when you don’t know how many of each type of study your group will be receiving. A month in advance, let alone a year. If you wind up with more XR and fewer MR than you expected, you might find yourself in a fiscal hole.

Every level of complexity that gets added to per-click schemes introduces new hassles in bean-counting. Ways for the unforeseen to sneak in and mess things up. Wrinkles that will create winners and losers amongst the rads (or seem to, and someone perceiving he’s being done out of something will make just as much noise as if he genuinely has). Unsurprising, then, that more than a few who’ve worked as per-click rads…or overseen them…have less-than-fond memories of the experience.

Meanwhile, a lot of the rads flocking to per-click groups do so because, philosophically, it appeals to them. A lot have previously experienced salaried jobs where everybody’s supposedly on their honor to do their fair share of the work…but that doesn’t seem to pan out. Compensation fails to be proportional to productivity. “Pay per click,” or “eat what you kill,” goes a long way towards preventing that.

Hybrid plans might be most capable of satisfying all comers. A set salary, or hourly rate, coupled with the notion that someone is keeping an eye on who’s actually getting the work done. That could be in the form of a monthly, quarterly, or even annual incentive-payment…or simply periodic performance-reviews, with outliers at both ends of the spectrum being recognized and perhaps rewarded (or sanctioned).

The nice thing about such a system is that, with less of one’s total comp on the line, keeping tabs on every little click stops being so important. Rads have less of a motivation to cherry-pick, game the system, or complain about it. And there doesn’t have to be quite as much bean-counting aggravation behind the scenes.

Still, one doesn’t want to completely lose track of who’s doing the work. Tune in next time for my “double-curve” solution.

There doesn’t have to be quite as much bean-counting aggravation behind the scenes.

All Clicks Are Not Created Equal

Plugging away at my worklist last week, I received an alert-chime for an incoming email. Turned out to be from my Editor for this column, an FYI/housekeeping notification. I had a quick look, saw nothing objectionable, responded “looks good to me,” and went on with my daily grind.

Fast-forward 15 hours or so: I’m freshly awake. My sleep-fogged brain, otherwise taxed to its limit with getting some clothing on my body so I can venture downstairs to brew some coffee, fairly shrieks at me about an incorrect detail from that email that my prior, fully-awake self had blown by.

This is a common thing for me, and I suspect I’m far from alone. While often being Johnny-on-the-spot, my mind can turn up details or insights well after they would have been immediately relevant. Hours, days, sometimes even years after the fact.

When it happens, I’m reminded of the late/great Douglas Adams, of Hitchhiker’s Guide fame. He once likened an after-storm distant rumble of thunder to someone “saying ‘and another thing…’ twenty minutes after admitting he’d lost the argument.”

The phrase was humorously used as title for a follow-up to Adams’ books after his death, nearly 20 years afterwards. In it, the new author (with approval from Adams’ publisher and estate) wrote an amusing bit about the phenomenon of memory coughing up things that the conscious mind might or might not want at the time.

It meshes nicely with my imagination: I envision the conscious mind as routinely visiting the entrance of its memory, a warehouse which grows increasingly massive as one ages, learns, and experiences. In addition to constantly dropping stuff off for storage within, the conscious regularly requisitions memories to be brought out of storage: Computer passwords, old conversations, lyrics to songs from yesteryear, you name it.

Considering how huge and packed with stuff the warehouse is, it’s kind of amazing that anything at all can be produced immediately on request. Or even with a few minutes of attempted scouring.

The “and another thing” phenom happens when my conscious mind gives up those efforts and moves on without the recollection. That doesn’t mean the workers in the warehouse give up too, though. No, my request was received, and once that engine starts chugging along, it can keep going in the background with surprising persistence…even though I’m consciously unaware of it. When results turn up, they can be a complete “where the heck did that come from” surprise.

Some might consider such delayed payoff of little use, even annoying. I try not to look at it that way. Rather, I find that it’s of adaptive value to take satisfaction, even pleasure, in the effectiveness of this apparatus. Discounting it just because it didn’t happen on my preferred timetable is focusing on the wrong thing, like condemning a runner because he completed a marathon but failed to come in under the 4-hour mark.

I have no objective evidence to offer, but I’ve come to believe the metaphorical warehouse-workers know how their efforts are being received…and react accordingly. Prizing that an unearthed tidbit from the memory was retrieved at all gets them working that much better, even if they turned up their loot later than I might have found useful. I find I can practically train them to be more productive.

And more of it is useful than might be apparent at first blush. For instance, the common recognition of something clever one could have said in an argument last week. That exchange is over. No way to use that zinger now (George Costanza tried once, regarding some shrimp and a “jerk store”), so it’s pointless, right?

Well, maybe for that particular skirmish…but if you learned anything from the incident, you’re that much better armed for similar situations in your future. So what if the warehouse handed you an obsolete gizmo? Don’t just toss it aside; give it its due. Mentally dissect it. Think about why it would have been a good retort (or if it could have gone wrong in some other way).

This goes for bigger things than verbal spats. Rehashing interactions with other rads, referrers, techs, administrative types can yield all sorts of “I’ll do it better next time” or “I did well with that; need to remember to use that approach again” insights for future use.

And sometimes, it’s not too late to take action. More than once in a blue moon, I’ll be in the middle of reading a case when I suddenly remember something I said (or failed to say) in a report earlier that day, even that week. I should have said this instead, shouldn’t have dictated that, or meant to make some other comment too.

At the very least, recognizing such would’ve/should’ves incrementally makes me less likely to make such errors in the future…but, courtesy of most RIS-platforms I’ve seen in recent years, I can still remedy them by going back in my “completed jobs” list and digging up the case to make an addendum.

Of course, I’m not going to remember the patient’s name to specifically hunt…but I’ll remember the body-part and modality. Sifting back through the list and clicking on relevant contenders can get me the case pretty quickly if I read it earlier that day, even that week. And most software I’ve worked with can go back even further than that.

Considering how huge and packed with stuff the warehouse is, it’s kind of amazing that anything at all can be produced immediately on request.

Making the Most of Your Mental Warehouse 

A couple of weeks ago, my lady and I attended a “food truck festival” event on the grounds of a nearby shopping-outlet. No idea how many years this thing had been going on, but the organizers hadn’t learned very much in the process. All of the logistics that could matter were poorly executed, if addressed at all.

That included parking. There’s no shortage of space on all sides of the outlets, which want to have capacity for as many shopping-visitors as possible. Driving into the place, however, there wasn’t a single sign to direct attendees to the side where the event was. Further, each parking area was set up so there would be one, maybe two ways in/out for hundreds of parking-spots.

So, once a visitor had enough of the event and decided to leave, s/he’d discover that extracting a vehicle from the place was a nightmare, because there was already a traffic-jam of other vehicles trying to do the same thing…and good luck getting any of those frustrated people to hang back and let you ahead of them in line towards the exit. There was also no telling where the lineup began. Lots of people couldn’t even back their cars out of their spots.

On the way towards our car, we encountered another would-be departee who’d been staffing a solar-panels booth at the event. Their purpose was to talk up the technology and enlist people for a home-visit, estimate, etc. One of those “you pay nothing and your electricity bills will drop” affairs that you’ve probably heard of.

I’d looked into it years ago and found that, at least in my case, I would most definitely be paying…enough that they offered me financing. Due to details of my particular house, power usage, etc., not a good deal at all. I knew it would be a waste of everybody’s time to talk with the solar-panel gal, and was more interested in getting to my vehicle so we could get on with the interminable wait to escape…

…but my lady engaged her in conversation, so I went along and didn’t mar the pleasantries by telling the gal she was barking up the wrong tree. Turned out she had the same first name as my lady’s younger sister, and I forget what other commonalities. A few minutes later, we proceeded on our way.

Not long after, we’d gotten in position to try breaking into the line of cars leading towards the exit…and lo and behold, the car situated to take pity on us and let us in was driven by the solar panel gal. We gave her big ol’ grins and a wave, and she had no real excuse not to let us go. Escape-time and stress were thus drastically reduced for us.

Had we not taken the time to be friendly and maybe let her think she was wooing customers, we would just have been other faces in the crowd, and there would have been no reason for her to let us in. Unbeknownst to us at the time, our chatting with her was an investment that yielded dividends in our quest to escape the parking-lot.

Rare as it is for the turnaround on such an investment to be so quick, I’ve found it to be a not-uncommon phenomenon: Be good to people, do nice things, and you might just find yourself rewarded for it down the line.

Phrased another way by an erstwhile residency-mate, consoling a peer about some downturn in the job-market or other negative forecast on future professional success: If you’ve put in the time and effort, sooner or later you’ll have something coming back to you.

It takes a little leap of faith to make this work. What you don’t want to do is keep careful tabs on who you did what favor for, how and when you expect them to repay you, etc. Not only does that greatly increase the effort you’re investing, it will make you very aware of—and possibly bitter about—all of the times you don’t see yourself repaid. Plus, other people pick up on that very quickly and come to know that any favor from you comes with strings attached.

Instead, think of it more as “casting your bread on the waters.” You don’t know how, when, or if you’ll see dividends…and you might not even recognize them when they come your way. They might simply seem to be pennies from heaven.

Freely give of your time to other rads in your group for curbside consultations. Help techs out when they have logistical issues. Be generous with advice and feedback to other rads, even med students earlier in their careers than you who are seeking guidance. One of them might someday be in a position to help you.

Maybe payback won’t come directly from them to you. Perhaps the rad you assist at no direct benefit to yourself will be inspired to follow your example, and help others. The circle of “paying it forward” could eventually come back to you, and you’d never know that you got it started.

If you’ve put in the time and effort, sooner or later you’ll have something coming back to you.