One thing our recent discussions of the nationwide shortage of radiologists didn’t include (in addition to a solution) is how the shortage has impacted the culture of radiology:
Pulse and a License
One of the concerning features of the current staffing shortage is the desperation with which many universities/hospitals/groups are recruiting new talent. When the market is tight and groups are well-staffed, groups get to be picky about cultural fit. Groups prioritizing compensation or efficiency can recruit fast radiologists or those with a broad skillset and flexible attitude. Groups that prioritize quality, academic productivity, or relationship-building can at least attempt to select for proxy features. Groups can grow in ways that align with their culture and mission.
But when there is far too much work to do and not enough people to do it, priorities shift to things like having a pulse and an active medical license, hopefully without board complaints or a felony record.
In Jim Collins’ Good to Great, there is a whole chapter dedicated to hiring. He argues that the key to creating a great business is not the mission or values, a charismatic leader, technology, or a clever strategic plan. The key foundation on which all other components rest is having the right people.
Sabotaging culture to generate revenues or get the work done may feel like a necessary choice in the short term (it also may be unavoidable when the alternative is operational insolvency), but it also has long-term consequences. Culture isn’t something you speak to; it is something that arises organically from good people doing things they believe in. As Collins says, “The best people don’t need to be managed.”
Fast Readers vs Practice Builders
One of the ways that cultural breakdowns manifest in radiology practices is the conflict between fast readers and practice builders (or, in academics: gold-star earners vs worker bees). Obviously, there are efficient radiologists who can do everything well, churning out an incredible volume of high-quality reports, and there are lazy people who do a bad job producing a relative molehill. Real life is a continuum, but the fake dichotomy is helpful for discussion.
I’m not even going to pretend that one is good or bad. The reality is that each of us is on a continuous spectrum as opposed to a caricature at the ends of the curve. The problem is that both extremes are real approaches and that good people in each camp become frustrated when the culture of the group does not align with their personal preferences. I see this discussed online all the time. Fast readers bemoan the freeloaders who are being paid the same or a similar amount for “less work.” But practices also rely on good citizens to get the important but non-remunerative work done. As an organization scales–and many groups have grown significantly over the past decade–reconciling these competing visions for an ideal radiology practice can seem impossible.
From a practice competition standpoint, it’s easy for a group to fall into a no man’s land where the compensation plan doesn’t reward speed enough for the high-productivity readers to be happy or rewards speed too much for the less “productive” members who get bogged down in the most complex cases, want more time to produce helpfully detailed reports, speak to clinicians, answer technologist questions, or teach residents. This can be compounded to disastrous effect by the cherry-picking that ravages some practices utilizing a productivity model, especially those that do not enforce list hygiene through automatic case assignment or customized internal work units to balance case desirability. If you log into a list and it’s full of plain films, thyroid ultrasounds, and chest CTs, you are logging into an environment where this hasn’t been figured out yet.
We touched on this previously in quality, speed, and “productivity”–and I didn’t have a magic bullet in that discussion either. These are real problems, and if there was a universal easy solution, everyone would be doing it. My feeling, as concluded in that brief article, is that the table stakes in the future are to automate case assignment ± customized internal RVUs to better account for effort ± account for “work” RVUs for nonbillable tasks (but bean counting every single thing you do has its own very real negative consequences). The quality/speed tradeoff is inherent to radiology work, but a productivity model that doesn’t take some variation of this into account is too ripe for cheating and gamesmanship.
Culture isn’t Optional; It’s Organic
My argument with the first two sections of this post is that compromising on hiring and being passive with internal work divisions and the productivity question are a one-two punch. I increasingly believe that places that don’t figure this out become revolving doors. At that point, recruitment is purely mercenary based on measurables. There are people who are willing to work that way, but long term, I don’t believe that leads to satisfaction or stability.
Culture happens whether we want it to or not, and creating a job that people enjoy and are loyal to doesn’t happen by accident. We are in a period of increased volatility in the radiology workforce regardless of what a practice does, but any job can become more stable if it feels like a meaningful career.