Where Are the Reinforcements??!?

Radiology could benefit from actions that support and encourage productivity.

Regular readers of this column have probably noticed my abiding interest in psychology. Particularly attentive, longer-term readers might even remember that my undergrad degree was on the subject or that I had originally gone to med school with the intention of specializing in psychiatry.

It, thus, caught my attention when a podcaster I like shared a theory on the subject of reinforcement and the diminishment of a societal work-ethic.

First, a brief explanation of reinforcement for those not in the know: A reinforcement is anything that happens after a behavior is performed, which results in more of that behavior. For instance, a morsel of food, if you’re trying to train a dog (as is currently happening in my house)…but the intention of the reinforcement is irrelevant. You can inadvertently reinforce unwanted behaviors, as well as the ones you’d like to see.

The important thing about reinforcement is that the subject perceives a connection between it and whatever behavior is being shaped. So if I give a treat to my doggo after she responds to a command, “Sit,” she might learn to sit after hearing that word. But she’s also tried sitting whenever she wants a treat (or something else), even when no command was given.

A reinforcement’s strength results from how closely it is tied to the behavior in the mind of the subject. The more thought it takes to connect the two, the more other variables have a chance to insert themselves, the weaker the reinforcement becomes.

Back to the podcaster: He recalled when direct deposit was becoming a thing, instead of checks handed out on payday. Yes, it was a nice convenience…but at the time he thought this might be the start of a bad trend. Getting handed a check on payday was a nice, tangible reinforcement to people for the work they were doing. That was being removed from the equation.

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Of course, people still know they’re being paid with direct deposit, but there’s less awareness of it. They might not review monthly bank statements to see the deposits, for example…or their expenses might routinely counterbalance the monetary inflow such that their account never seems to enlarge. The sensation of “here’s my reward for what I’ve done” becomes rare to the point of non-existence for some folks—hence the podcaster’s concern about erosion of society’s work ethic, as a whole.

When I switched to teleradiology back in 2011, my direct deposits became a monthly affair, rather than the biweekly schedule I’d previously experienced. I can’t speak for all of the telerad entities out there, but monthly is the way of things for every one I’ve encountered. Even some conventional, onsite gigs. It’s logistically easier for the bean-counting and bookkeeping types.

However, the thought has occurred to me – more than a few times – that this further separates reinforcement from the behavior it’s supposed to be shaping. We intelligent, sophisticated humans don’t need to be fed a treat every time we behave well…but making the work-reward connection ever-more oblique doesn’t increase motivation.

Especially when the bits of work we do are so often accompanied by aversive, punishment-like results: A cast of characters (referrers, quality assurance (QA)-colleagues, coding/billing staff) telling us we erred, various other interruptions impeding our productivity, glitchy software and malfunctioning hardware, seeing our worklists grow rather than shrink despite our reading at breakneck paces…I could go on.

Suppose a rad reads a hundred cases per day and such unpleasant things happen every ten cases. A month will result in a couple hundred of those mini-punishments (“aversive conditioning,” in psych-speak) for doing their job…and, then, sometime during the next month, there’s a solitary direct deposit that they might not even notice. Psychologically, that’s not a formula for winding up with a great feeling about their work.

The remedy for this, to my way of thinking, is finding ways to diminish the frequency of aversive-conditioning events and increase the frequency of positive reinforcement. No, that doesn’t mean attaching an ATM to a rad’s workstation and have it pump out money as RVUs are generated (although I do think that would be an interesting experiment to perform). I also don’t think we’re going back to old-style paychecks anytime soon.

It’s additionally become evident to me that even a routine reminder of “you’re getting paid X to do this work” is of diminishing reinforcement value. People adjust to their circumstances; what was once an impressive compensation package gradually turns into the status quo and, eventually, even less than. If one comes to feel like one deserves X-plus, continuing to get X no longer feels like much of a reward.

I’d suggest finding other ways to positively reinforce rads doing what they’re supposed to. Which, in a lot of instances, would be more of a re-discovery, since most of it wouldn’t be groundbreaking, unheard-of stuff…more like common-sense niceties that have gradually fallen into disuse.

I’ve discussed a couple of initiatives that could do just that, in columns gone by…one of which being positive, affirming-style QA. That is, not every QA episode needs to be a negative statement about a rad’s work. Indeed, I maintain that it would be better for QA to be more than 50 percent composed of “Good call, that was a subtle abnormality!” or “I learned something reviewing this case you read.”

If I hear from readers (for instance, on my Twitter page) that there’s interest in some of these other positive reinforcements that could easily pepper a typical rad’s month of work…rather than solely relying on occasional, unseen digital fund-transfers to prop up his spirits…I’ll revisit this and dive a bit deeper.

Follow Editorial Board member Eric Postal, M.D., on Twitter, @EricPostal_MD.