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Self-QA in Radiology: My Harshest Critic and My Number One Fan


How strong is your own quality assurance (QA) barometer for interpreting CT, MRI, and ultrasound images?

I have said a thing or two about quality assurance (QA) in this blog over the years. Long-term readers may recall that I am often unimpressed with the way it is executed.

One of the factors feeding into that is my lifelong tendency toward perfectionism. I am prone to beating myself up over all sorts of petty things that most non-neurotic people wouldn’t give a second thought. If I make a diagnostic error, I will torment myself for it more than enough. The way QA brings others into the mix often simply pours psychological salt onto the wound without adding any value.

It is not hard to see how a career in medicine would select for, and breed, perfectionist types. One competes against classmates from an early age to have the best scholastic profile, academic and otherwise. A score of 99 out of 100 easily shifts from an attitude of “Well done!” to “What happened to that last point?” Even a perfect grade can go from a cause for celebration to a mere acceptance of meeting expectations.

Most perfectionists eventually have a showdown with the reality that they are not, in fact, perfect. After enough ego-bruising episodes of imperfection, a well-adjusted individual might do some soul searching and realize that a little mortal fallibility doesn’t nullify his or her whole existence. Those less adaptable may find the process more traumatizing.

Afterward, I don’t think perfectionism totally goes away. For a lot of folks (myself included), it just gets taken down a few pegs to the point where the former perfectionist still holds lofty self-expectations that are well above those held for (or by) others. One remains one’s own harshest critic.

That can be helpful in providing an endless source of motivation for improvement and doing bigger and better things. I might occasionally wish I was more forgiving with myself (in the name of less self-inflicted stress), but that lack of self-forgiveness is responsible for a lot of my achievements.

Being my own harshest critic serves as a sort of self-QA. If I am doing anything that matters, I know that I will be giving it my best effort. I can become my own biggest fan for that. Other folks have no way of knowing just how much self-policing is going on in me as they are only seeing what I produce. In their eyes, it’s probably not perfect and they have no awareness that it’s as close to perfection as I can reasonably get. For all they know, I could be “mailing it in.” I can tell them that I’m doing my best, but how liable are they to be convinced by those cheap words.

Indeed, most of us have a strong sense that the world is full of people who aren’t giving things their all. I suppose one could believe that anybody who does (and isn’t filthy rich or famous as a result) is kind of a sucker for trying so much harder without anything to show for it. I’m more of the mind that it is one of the few things genuinely worthy of pride.

Being your own biggest fan is, of course, entirely possible without being your harshest critic first. You can probably think of a few egomaniacs who have done nothing to earn their inflated sense of self. There are also more than a few folks who have found ways to be justifiably self-satisfied without previously beating themselves up for a chunk of their lives to earn the privilege. I envy them a little but know that I depend on my self-criticism to “keep me honest.”

Being one’s own biggest fan is protective. There is only so much that others are going to make a point of singing your praises, even if you somehow manage perfect performance. When they’re not doing so, either you’ve got to pat yourself on the back or nobody will.

When it comes to radiology, there are more than a few opportunities to self-criticize or praise. If, like me, you’re a reformed perfectionist, the criticism comes a lot more readily (and involuntarily). Pretty much anything you do is fertile ground: You can beat yourself up over RVU tallies, cleaned-up worklists, QA stats of course, requested addenda (“I should have phrased my report, so they didn’t need to ask that!”), team organizational efforts, you name it.

Being your own number one fan can require more conscious effort, but it still comes naturally for the things that strongly matter to you. For instance, when I first switched into telerad and my comp was purely per-click, I got keenly aware of my RVUs and could break them down in a bunch of different ways. It didn’t take me long to see that I was in the higher productivity percentiles of my large rad group, and to value that about myself.

Subsequent jobs weren’t per-click, but I had already incorporated strong productivity into my professional sense of self. That turned out to be very helpful when those jobs had less efficient infrastructures that simply didn’t allow for the high RVU tallies of which I had already proven capable. If I hadn’t already become a pretty big fan of myself in that regard, I might have worried. Was I not competitive, or becoming a slacker? What would others think of me?

A similar phenomenon can occur with QA. Work long enough and you get a sense of your accuracy: A “minor miss” every few months, perhaps, and something bigger once in a thankfully rare blue moon. Now you switch into a new gig or start covering for a different facility with a new cast of characters reviewing your reports. Suddenly, you’re getting flagged reports every day.

If you had started out in such an environment, you might panic. Am I really that bad? However, with a background that showed you your accuracy was something to be proud of, you have a better chance to weather the storm. Either recognize that you’re being needlessly harassed by nitpickers and don’t let it get to you or face the issue head-on and advise whoever’s running the QA program that it is causing more harm than good since you already know you are not the problem.

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