Pressure and Time: Radiology’s Slow March Toward Improvement

It has been observed by more than a few people, including radiologists, that humans are pattern recognition machines. Indeed, we often connect dots that have no business being connected, a la conspiracy theories.

When the dots are subjective affairs, however, nobody can say you are wrong. In last week’s blog, I wrote of my impression that, over the course of my 20-ish years as a radiologist, addendum requests — in particular my ability to respond to them — have trended in a reasonable direction. I mentioned a couple of contributing factors, not the least of which being a rad-friendly job-market.

The piece I wrote lingered in my mind for a few days, and I found myself thinking that a number of other things have improved during my tenure. Most, if not all, of them can also be attributed to the job market or, taking a broader view, the supply-demand imbalance in the radiological field.

Hearing talk of supply and demand, it is easy to think of casts of characters like customers, vendors, and manufacturers. Character A does this (raises prices for instance) and character B reacts by doing that (buying less, or shopping elsewhere). It feels good to think about things this way, in part because we like the idea of having a modicum of control. If my job or profession at large does something I don’t like, I can react to improve things or one of my peers might.

Unfortunately for that worldview, a lot of smart, innovative, and hardworking rads throw themselves against the imperfections (and downright absurdities) of our professional world on a regular basis, and do not succeed. Many instead suffer personal setbacks, getting labeled as malcontents or even “disruptive physicians” for trying to buck the system. At the very least, they expend their energies and wind up with nothing but disillusionment to show for it.

I have thus found myself thinking along the lines of Red’s description of geology in The Shawshank Redemption. Pressure and time have led to improvement.

In the case of radiology’s worsening imbalance (too much work to be done by too few rads), the pressure is on to get ever more cases done within a certain interval of time. Part of that pressure is a need (or at least want) for the work to be done in a certain way. Achieving diagnostic accuracy while abiding by certain “best practices” appeases regulators, payors, referrers, and patients, etc.

That last batch of pressure elements is the most easily sacrificed. The cases are going to get done one way or another. They might exceed turnaround time (TAT) expectations, they might fail to satisfy insurance companies and thus go unpaid, or they might annoy referrers for various reasons. It is like squeezing a water balloon that only has a small outflow. If you squeeze too hard or too suddenly, the balloon will pop. The water gets out. It is just a question of how (un)controlled the process is.

Occasionally, a rad or someone else in the system happens to be in the right place at the right time and gets the water flowing out a little better without a messy popping of the balloon. We might point at that individual as a visionary. He or she might be named medical director of some corporate rad group or rad advocacy entity in the hope that he or she will continue to be associated with systemic improvements. If we are lucky, this rad actually has the skills and drive to do it.

Since I mentioned geology, forget about the water balloon and think about things like rivers, tides, and occasional flood events with their respective impacts on the landscape. Waters exert pressure in the fullness of time, eroding riverbeds into canyons. The path of least resistance is almost always what is ultimately followed.

One example that leaps to mind. I am old enough to remember when it seemed like everybody had their own ideas about what to do with small pulmonary nodules and other incidentalomas. Referrers dissatisfied with this lack of uniformity would be one source of resistance: Can’t you guys come to some sort of consensus? Rads would be another source of resistance: Why can none of my colleagues do things the right (my) way? Alternatively, why isn’t there some accepted reference source I can refer to for these darned nodules?

Apply these pressures for enough time and solutions emerge (Fleischner Society guidelines and Lung-RADS). Are they perfect, and does everybody love them? No. Are they better than what was going on before? I think most of us who have been in the field long enough would say yes.

One could argue that the path of least resistance was responsible for radiology moving from transcriptionists to voice recognition software. Typing humans might initially have cost less than developing the new technology, but once the tech was in place, I have got to imagine the savings were enormous in part because such greater volumes of rad work could get done in a fraction of the time.

Pressure and time aren’t magically beneficial of course. I have mentioned how the supply/demand imbalance has resulted in a rising tide of non-rads doing work that, just a few years ago, was accepted as needing to be done by rads. One might consider that a case of the water balloon springing a leak in an undesirable way or a river’s flood waters inundating a nearby town.

While we never have complete control, if we are paying enough attention, we might take corrective action. For example, one might build up levees in the case of a river that we predict might flood someday. The flood may never occur and eventually somebody might even decry the preventive measures as having been a waste. On the other hand, enough time and pressure will probably overcome any countermeasures we can think of. That is what cost-benefit analysis is for.

I am not sure what, if anything, is being done for the “scope of practice” issues in radiology. Meanwhile, on another front, some folks have been sounding the alarm for AI taking over all our jobs and others are seeing ways that particular aspect of time/pressure might be harnessed. Having no crystal ball, I look back on the past couple of decades and choose to be optimistic that it, too, will ultimately be to the collective benefit.