Radiologists Staring Down the Barrel

May 11, 2012

From med-mal to reimbursement, radiologists have quite a few metaphorical guns to our collective heads.

An esteemed colleague of mine once challenged me with a case, diagnosis known to him but not yet to me. Looking at it, I came down to a two-item differential, and waffled between the two. He introduced me to a colorful metaphor: “If you had a gun to your head and had to choose one diagnosis, which would it be?”

Fortunately, life in the reading room is not quite so dramatic as to press firearm steel against noggin - at least not in the places I’ve worked so far (I’m told PPACA may change that if the Supreme Court doesn’t overturn it). Nevertheless, we’ve got quite a few metaphorical guns to our collective heads. Or swords of Damocles, if you prefer.

First is the gun held to the head of most who work for a living (except maybe civil servants): Produce, or lose your position. Seems reasonable enough. Who expects to get showered with cash without earning it in some way? Things get a little murkier when you start introducing some details, though - like just how much one is expected to produce, and under what circumstances. And how the requirements change with time. A new departmental edict that thou shalt henceforth read 30,000 cases per year with a 0 percent error rate, for instance.

Second is a little more peculiar to our profession: The med-mal gun. Anything you do at work (or allegedly fail to do) can result in an unwelcome delivery to your doorstep, years down the line, after which you will be subjected to the tender mercies of our tort system.

Even the most frivolous garbage lawsuit of them all can drag on interminably, cost you a bundle in legal defense (and lost productivity from your job), and generally make you a nervous wreck. Plus, even if you come out spotlessly vindicated, you’ll be listing the incident on applications for the rest of your career.

Some more guns are courtesy of the insurance industry and government’s growing stranglehold on the healthcare biz: A never-ending increase in the contortions we must perform to remain in the good graces of third parties who get to decide how and when (and whether) to pay us for services rendered. Running afoul of a private insurer is bad enough, if it’s a major part of your payer-mix, but government can go beyond cutting off your livelihood, not only withholding payment from you but actually making you pay it via steep fines. Loss of licensure and even imprisonment are also in play.

Any decent self-defense instructor will tell you that if you have a gun pointed at you, your default reaction should be to comply with the gunman’s demands. Unless you’ve got reason to believe that compliance will not prevent the trigger from being pulled or something equally bad. In other words, go along unless it looks like you have nothing more to lose.

The gunman has similar considerations. He can only expect you’ll cooperate as long as you think you’ll eventually get out of this situation, and on to better times. The more he squeezes you, the greater the chance you’ll resist and force him to choose between pulling the trigger versus revealing that he won’t follow through on his threat.

Dealing with multiple gunmen results in more variables. None of them really has a good idea of (or control over) how much pressure the others are putting on their mutual target. The sum total of these threats can exceed the victim’s tolerance, when none of the individual threats would have, such that the target no longer perceives there’s a meaningful chance of a good outcome without desperate action.

I don’t think most of us are quite at that point yet. But I do think that our gunmen are steadily increasing their volume and menace, and pressing their steel more forcefully against our temples with the passage of time.