The Path of Least Resistance

June 23, 2017

Outsiders’ influence on radiology.

As with many of life’s more successful critters, we radiologists are adaptive types. Experiencing something, we modify our behavior to make it happen more-or less-frequently in the future.

We’re a bit more sophisticated than a quadruped in a Skinner box. Our motivations don’t have to be such basic things like sustenance or avoiding electrical shocks. They can be any number of steps removed. For instance, if we perceive something will impact our income, such as productivity in a pay-per-RVU job, that income is one step removed from all sorts of positive reinforcement (food, toys, vacations, etc.).

Two steps removed might be something that we believe might threaten our livelihood (losing a job, or indeed a license)…if we can’t work, even temporarily, that results in loss of income, and then the benefits of the last paragraph are in jeopardy. You get the idea.

It doesn’t even have to be tenuously connected to such important stuff. We routinely adapt to minimize unpleasantness, or maximize comfort. If something about our work is annoying, for instance, we seek to diminish or eliminate it.

So, when the world intrudes upon our work in a way we don’t like, we resist. That is, unless the consequences of resisting are worse. Or, our resistance turns out to be less effective than we’d hoped, and/or effortful to the point that continuing to resist is more of a hassle than just enduring the intrusion for the visible future.

Which, at least in my experience, is very frequently the case. There is an ever increasing list of ways I’d practice radiology differently (and, I believe, better), if the consequences weren’t less palatable to me than the status quo.

I think a lot of the clinicians who depend on us for their patients’ diagnostic imaging would do well to keep this in mind, whenever they impose their will upon us. By that, I mean requesting/demanding that we do our work their way, with the oft-unspoken leverage that, if we don’t, they’ll make things politically difficult for us in our shared health care facility…or simply send their patients elsewhere.

A given clinician might not think about this aspect when they are flexing such muscle. They want specific verbiage in their patients’ reports, for instance, or they want their patients given priority over other referrers’ patients. It might genuinely not occur to them that, if they can coerce us, others can too…especially once our resistance has been beaten down by the first few rounds of coercion. And some clinicians probably won’t much care for the excess verbiage that others have managed to finagle into our reports.

That doesn’t just go for referring clinicians. Hospital administrators, our own departmental leaders, insurance companies, even governmental types and regulators have all gotten quite comfortable meddling with our work. Each one might think that his/her particular bit of interference is wise, just, and helpful. Meanwhile, their impact might be downright unwelcome to everyone else (not just us rads)…including the patients, lest we forget who this is really all supposed to be about.

So, for instance, some states require a thick, wordy paragraph to be inserted into a mammogram report whenever a patient has dense tissue. Some patients, seeing this, might get worried, and contact their primary care docs for reassurance (and primary care types aren’t exactly lacking for things to do with their time). Indeed, the primary care docs might now wonder what the heck they’re supposed to do about it.

Or, CMS might insist that an abdominal ultrasound contain references to the aorta and IVC if the rad hopes to receive payment. The rad knows that, in the vast majority of the sonos he gets, these vessels aren’t really seen sufficiently for diagnostic comment. The path of least resistance will nevertheless be for the report to say something like “As seen, the aorta and cava are unremarkable.” Will non-rads, seeing these reports, think that means pathology has reliably been excluded? Probably.

I really wish there was a way to simultaneously get the attention of referrers, insurers, and others who have this kind of influence on our work, if only to say, “Be careful what you wish for.” I think we’ve long since passed the time when we, the rads, had a meaningful ability to say NO when approached with yet another outsider’s idea of how we should do our job. The best hope we have for our reports to not degenerate further into a Tower of Babel might now be hoping for restraint on the part of non-radiologists.