A Halloween Pumpkin Metaphor for Radiologists

I have referenced some cherished comedians of yore in my blog. The greats went beyond mere jokes: They delved into social commentary and waxed philosophical while remaining funny. Many latter-day performers seem to have ditched the ha-ha element, pursuing “I agree with you” claps instead of “you made me laugh” claps. Good for them if they can make ends meet that way, but they will do it without me in their audience.

One of the good ones (Adam Carolla, giving credit where credit is due) had a bit about Halloween candy. He told of families that wouldn’t be around to personally distribute sugary stuff at their door, opting to leave plastic pumpkins filled with it, accompanied by a friendly sign: “Please only take one and leave the rest for other visitors.”

Most of us agree it would be nice if we were in a world where that worked or even if a majority of neighborhoods could function like that. Unfortunately, an unwatched pumpkin commonly gets upended into one kid’s loot-bag, and all subsequent arrivals see it empty.

Many of them just get disappointed at the harsh reminder of our imperfect world and don’t let it distort their own behavior. Some might think, “Hey, the thief got away with it,” and become a pumpkin dumper themselves when future opportunities arise. They might rationalize that they are simply getting their due for all the times they have seen an empty pumpkin or might in the future.

Enough folks getting away with misbehavior at one level eventually emboldens others to misbehave with greater severity. Some kids might escalate by spitting in the empty pumpkin (Carolla actually used a verb that rhymed but was cruder and thus funnier. I don’t work blue here). The candy-less pumpkin might ultimately get hurled through the poor homeowner’s window.

Again, it would be nice if we lived in a world where people could be trusted to behave themselves when they aren’t being watched or otherwise don’t expect to be held accountable. Some of us wish for that sufficiently strongly that we resist doing anything to police them. We shouldn’t have to do this. That goes extra for folks we are supposed to regard with trust and respect, such as physicians.

It traditionally gets kicked up a few more notches when docs are dealing with one another: Collegiality and professionalism were at one time practically supposed to keep us from even thinking of our teammates behaving badly, let alone accuse them of it.

Unfortunately, whenever there is sufficient potential for personal gain and insufficient risk of being caught, corruption will happen. One doesn’t have to be particularly evil to be guilty of it. If you leave a big pile of money lying on a table with enough people passing by, that money is going to vanish, even if no career criminals are around. Depending on your political views, Minnesota might or might not be a good example.

Not only that, but folks who get such loot (especially more than once) undergo psychological contortions to justify it. I stumbled across a quote from author Daniel Nayeri: “If you don’t get caught, you deserve everything you steal.”

I reiterate that you don’t have to be an actual thief. Circumstances may have thrown good stuff into your lap. Perhaps you saw no way anybody else was really being harmed by your gain, so you kept it. Maybe you eventually come to realize how your windfall occurred, and how to make it happen again. Perhaps you conclude others have done similar (or worse), and this is how the scales of justice are going to be rebalanced, so you get your fair share.

How many empty pumpkins have crossed your radiological path, who you believe emptied them, and how you react will vary widely. I recall some high-profile CMS fraud case in my area, years back, from a rad group which was getting extra reimbursements by claiming a lot of 3D recons that either weren’t warranted or not being done at all.

Not knowing any of the rads involved, I can’t be sure, but I wouldn’t be surprised if that fraudulent ball got rolling because they had noticed they were suffering reimbursement cuts every year as the government played at being budget neutral with health care. Those rads might have decided that politicians had emptied the radiology pumpkin, our professional societies had failed to stand guard, and such fraud was a way for them to make up the loss.

Most rads have noticed the same empty pumpkin. The vast majority of us (I hope) haven’t reacted by committing fraud, but we have reacted. The ignobility of any particular one of those reactions would be in the eye of the beholder.

Early in my career, I got an empty pumpkin when, after four-plus years of good faith work in a partnership track, a real partnership failed to be offered. I didn’t even get offered a raise. I might have reacted by staying in that job and just cutting way back on my productivity, but instead I bailed out to go work in a per-click environment. I gave myself a “raise” by moving to productivity-based payment, not some hierarchical salary system.

One might be charitable and say that the folks running the per-click environment were being more honorable by rewarding those who worked harder. Pragmatically, I just think it was a stronger business model. The best solution to avoid empty pumpkin situations isn’t to hope that people will be nicer, or even to berate them on the rare occasion that you catch them being ugly.

What works more reliably is to institute mechanisms whereby people know they are being watched, making bad behavior difficult or impossible to get away with. With the Halloween metaphor, that might mean getting rid of the plastic pumpkin and actually being there to hand out the goodies yourself. Alternatively, maybe you get a video doorbell with a nice, bright light. Many would-be pumpkin dumpers will refrain if they know they are being recorded.