In Give and Take, Adam Grant divides people into three types: givers, takers, and matchers.

• Takers try to get more than they give.
• Matchers aim for even trades.
• Givers help without expectation.

Grant argues that givers are both the most and the least successful (because people like givers, but they are also the easiest to take advantage of):

“Givers are overrepresented at the bottom and the top of the success ladder.”

Radiology practice is no exception. The culture is the people, and it arises organically from the people in the organization working within the constraints of the clinical work.

Picker of Cherries

Consider cherry-picking in radiology:

• Takers cherry-pick to get more RVUs, easier cases, or both.
• Matchers behave appropriately, unless they are working with known takers or see taking behavior, since people generally don’t like being taken advantage of.
• Givers read down the list and jump on the grenades left over by the others. This can result in looking less efficient by various metrics.

Conditional Behavior

The reality is that people’s behavior is both variable and domain-specific. Someone may run amok on the list but be willing to do tedious extra administrative work that no one wants to do. Someone may be a huge team player at the hospital when they’re part of a small group where they feel seen, but a bad actor when part of a massive shared list.

We need to acknowledge that 1) hiring matters, 2) culture matters, and 3) we should try to build better systems that make it easier for people to behave nicely and win.

It’s impossible, even in easy times, to hire right all the time. The solution, in the old days, was to make partnership contingent on good behavior (and, sometimes, high productivity). The problem of course is that, like tenure, that doesn’t fix sloth or selfishness among partners. And certainly in the current market, dropping people when staffing is tenuous isn’t trivial when the work has to get done. Rug pulling too often would seriously harm a group’s reputation, and warm bodies don’t grow on trees.

Workflow-wise, too many metrics and too much surveillance are extremely toxic. No one wants to have their movements tracked like an Amazon warehouse worker to make sure their bathroom breaks are industry-conforming. The reality is that an open list where you select your next case is a big temptation for takers. And it only takes a tiny sliver of takers in an organization to spur the suboptimal behavior of matchers. That leaves everyone feeling like a distrusting victim.

Giving, More Broadly

Not all giving is equal. And not all of it scales.

“Being a giver doesn’t require extraordinary acts of sacrifice. It just involves a focus on acting in the interests of others.”

Matching is about dividing the work pie fairly, but giving often involves other gifts of time, energy, knowledge, skill, and emotional support. Teaching is a gift. Administrative duties like committee work, medical directorship, and practice leadership often disproportionately fall on givers. The “reward” for doing these tasks well (or even just being willing to do them) is often being given more responsibilities.

We can’t let giving be a suckers game:

“If you don’t protect yourself, giving can be dangerous.”

Give to matchers, and you build reciprocity.
Give to givers, and you build culture.
Give to takers, and you burn out.

Takers exploit. Matchers track. Givers build.

We need systems with guardrails to ensure that opportunities for exploitation are rare and that bad behavior can be policed effectively. If your group is using independent contractors for list support, that might mean giving them access to only a specific list or specific cases instead of letting them graze freely.

The problem is that if takers dominate, everyone becomes a matcher. Generosity becomes naïve. Trust becomes weakness. And the whole system corrodes.

“The more often people give without strings attached, the more others start to match their generosity.”

Practices thrive when givers can lead with open eyes and no remorse.

Here’s a little compilation of posts from the last few years about getting started as a new radiology resident.

Transitioning

Scan by Scan is an essay about starting in radiology.

Doing

Approaching the Radiology R1 Year and its short companion post: How to be a First-Year Radiology Resident.

Want something a little more controversial? You Should be Correlating Clinically.

Learning

Book Recommendations for First-Year Radiology Residents (and some further recommendations for when there’s extra book fund to burn).

You can round that out with some more general thoughts on studying during residency. Then try my deeper dive: ultralearning radiology.

Iterating

Some important considerations for getting better every day.

Getting and making the most of feedback. Also, a few more words about your self-worth as an early trainee.

Lastly, radiology call tips (which are also helpful every day).

Efficiency & Ergonomics

There’s a lot you can and should do other than just using whatever is plugged into your workstation, but this post for trainees is a start.

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Also, residents from across the country in the ACR Resident and Fellow Section came together and assembled a nice collection of free radiology learning resources from across the interwebs including lots of videos.

Headset vs. Handheld vs. Fixed Microphones

There are three main form factors for microphones in the context of a radiology setup.

You can hold a dictaphone, as radiologists have done since time immemorial. You can wear a microphone like a headset. Or you can have a microphone that is not in any way on your person.

There are pros and cons to each solution.

The pro of the old standby handheld microphone is that it contains dictation controls, allowing you to manipulate dictation software with your nondominant hand. As I’ve discussed elsewhere, this is the wrong solution for efficiency and for ergonomics. The limitations of the built-in dictaphone tools are too numerous for it to be the right answer—even though it is the default solution.

I believe every radiologist should drop the dictaphone and use something else with their off hand. An off-hand device like the one I use can more effectively manipulate both dictation software and PACS and is less likely to cause repetitive strain or ulnar neuropathy.

An off-body solution has the benefit of freeing up your hands while also remaining plug-and-play. The microphone stays where you put it and just works when you log in. No effort needed and—with the right microphone—can be very effective.

There are infinite options. The Rode VideoMic NTG, a shotgun microphone I attach to my monitor and point at my face, has been my home dictation solution for several years now. It is efficient, effective, and works every time. I find it effortless and surprisingly resilient to slouching. The main downside to that solution is that you are still somewhat more susceptible to ambient room noise and posture.

For some radiologists, the preferred solution is a headset microphone, which has the added benefit of moving with you so that it always accounts for position regardless of where you are relative to your desk and is less susceptible to ambient noise.

While you could also use a lav mic clipped to your clothing, but a headset also allows you to use headphones with your computer, meaning you can handle meeting requests like Zoom/Teams and listen to music without needing a second device.

For many years, headsets for dictation functionally required a wired USB connection, as Bluetooth and wireless dongles were simply too unstable, slow, and choppy for dictation accuracy. But if you don’t mind a little lag, that is no longer the case.

Headsets, like headphones more generally are very much a personal preference thing. I included several fan favorites in the equipment post, but my preferred headset solution is these Shokz bone-conduction headphones, specifically the Shokz OpenComm2 UC for several reasons. This style has become very popular with runners because you can’t lose them as easily as earbuds and you can still hear the ambient world around you for safety (I still like the AirPods Pro 2 with transparency mode).

One perk is that the Shokz are incredibly light and comfortable for long periods of time. Over-ear headphones can feel hot and are often heavier, resulting in fatigue over a long shift. There was a time as an early attending that I often used a cheap wired Plantronics headset, but I actually usually wore them around my neck with the mic arm angled toward my mouth for comfort. I think the over-the-ear behind-the-head form factor is overall more comfortable for long-term use. The Shokz are light enough that it’s basically possible to forget you’re wearing them, which I would say is ideal.

The bone-conduction pads on your tragus are non-intrusive and do not block ambient noise. This can be both a pro and a con—in the sense that if you are working in a loud place (such as next to the magnet or at home while doing laundry), you are not going to block out the room noise.

But it also helps if you want to deploy a headset while working with other human beings and wanting to be able to hear the noise around you. It means people can talk to you, and you can hear them—and that you can answer the phone and still use a receiver without needing to remove your headset.

So, for some work situations, this is ideal.

The battery lasts for a long time (reported 16 hours of dictation, 8 hours if playing music), though one downside is that the charging cable is proprietary—so you’ll have to keep the cord handy for charging (it fits in the included carrying case). A 5-minute quick charge provides 2 hours of talk time. I haven’t had battery issues yet, but since the tiny battery inside is like literally every other lithium battery in the world, I expect this to degrade eventually.

You can connect via Bluetooth, but it also plugs in easily with a USB-C (or USB-A) dongle that is safely secured in the carrying case. My understanding is that the quality with the dongle is slightly better.

If you are looking for a portable solution that reliably works, allows you to use them as functional headphones and attend Zoom/Teams calls—but also doesn’t isolate you from the rest of the world—the Shokz is, I think, a good solution for radiology.

A couple of very important limitations:

1. There is a slight lag when activating dictation, where you might notice degraded accuracy at the beginning of a phrase. You really need to use toggle on/off controls and not the deadman switch, and your accuracy will be way better if you just keep dictation turned on while reporting. Once dictation kicks on, transcription speed is fast and accurate. I think you will need to break the habit or toggling dictation on/off repeatedly for every discrete phrase or you will hate them.
2. Audio quality is lower when you’re actively using the microphone dictating, so if you are toggling back and forth all the time it’ll keep switching between higher and lower fidelity modes. It’s annoying. Bone conduction headphones aren’t audiophile quality anyway, but you’ve been warned. Because your ears are uncovered, if you don’t mind looking like a psychopath, you can keep AirPods in your ears while wearing the headset, which means you can have incredibly flexible audio input/output between your computer and cellphone. I wouldn’t listen to music via them while working.

I’ve been using the Shokz as an alternative to my cheap desk-clamp-to-hold-the-dictaphone method when at imaging centers, which allows for some more position flexibility (and the chance to channel your inner telemarketer.)

If you don’t need the headphones part of the headset but want something portable, you might instead try a lavalier format like the wireless Hollyland M2S.

It’s easy to measure radiologist productivity in terms of RVUs per hour.

What’s harder to assess is how efficiently a radiologist reaches that production number—both cognitively and psychologically.

I’ve written a lot about the biomechanical side of reducing friction in the radiology workflow: better input devices like programmable mice, off-hand keypads, and simple AutoHotkey scripts. But there’s another important piece—minimizing distractions and maintaining momentum from case to case.

On the macro shift level, you can have so-called bunker shifts free of technologist and clinician phone calls and other external distractions. Literature has shown, big surprise, that on the whole, people read more if you don’t interrupt them. But there are two issues with that:

1. Talking to people is part of the job, at least some of the time.
2. You can still distract yourself.

Auto Advance

One simple but powerful tool is AutoNext or equivalent automatic case-loading function in your worklist manager. When you sign a case, the next one opens automatically.

This reduces the liminal space between cases—those tiny gaps where your monkey mind looks for distraction, dopamine, or the occasional excuse to manipulate a shared worklist to avoid difficult or low-RVU studies.

(We can however acknowledge that automatic case selection/loading can increase the feeling of being on an endless hamster wheel, but overall I still believe it’s ultimately effective in removing some useless clicks and unnecessary decisions.)

Enough with the Email

Another low-effort win: don’t keep your email open in a browser tab. Just closing the tab dramatically reduces the urge to check email every five seconds between cases, especially when you can see the unread message counter climbing.

We are always looking for an excuse to disengage when a task gets hard. Your phone may be in your pocket, and you may need to be reachable, but it’s still better to batch-check email sporadically than to leave it constantly accessible.

Phone Just Out of Arm’s Reach

I need to be able to answer the phone. Anyone who needs me generally is going to call my cell or text, and I also forward the hospital phones to my cell phone when covering from home. This is one reason why I often keep an AirPod or two in my ears most of the time when I’m working alone: I can hear and answer the demand without needing to have my phone on my person. Just a little friction can go a long way.

Creating vs Editing

One feature I’ve come to really appreciate in my practice is access to a team of human editors (the imaging center pays)—someone who helps input clinical histories, contrast details, catch template mismatches, and fix obvious transcription errors. They’re not perfect, and they certainly don’t always make big changes, but the value isn’t just in the edits themselves.

What the editor allows me to do (only when I’m on an outpatient list) is separate the diagnostic report creation task from the editing task. I can read multiple cases in a row, focusing on interpretation and moving efficiently down the list—then switch into editor mode to proofread and finalize my reports. I catch more of my own mistakes with those few minutes of temporal distance.

This separation is key. Constantly switching back and forth between different cognitive modes creates attention residue (not to mention editing fresh words is always a challenge as your mind often sees what you meant to say and not what’s actually there).

While avoiding distractions like email, phones, and messages is intuitive but challenging, task batching is an overlooked opportunity (obviously only when working on non-time-sensitive cases). Diagnostic, then editorial. Not both at once. It’s a subtle shift, but I’ve found that when practical it makes a real difference in my focus, efficiency, and effectiveness.