Radiologist in a Skinner Box: How to (De)program Yourself and Your Colleagues

If you made it through med school, you learned a bit about mental health. If you had undergrad courses in psychology or cognitive science, you may have had an earlier start.

The material is of greater interest to some than others. One doesn’t need to go on to specialize in psychiatry to find value in remembering it, or even applying it to daily life. It can be introspective (“Why do I feel/think/act this way?”), or it can be directed outward to anyone from family to complete strangers.

While I have always been intrigued by the more abstract aspects of psych (Freud and Jung for instance), I find other approaches more practical when it comes to getting real-world results. It might bruise our human ego, but the same stimulus-response and behavior-reinforcement dynamics that worked in animals for Pavlov and Skinner do a pretty reliable job with us too.

Behavioral training depends on repetition. Sometimes we clever, evolved monkeys don’t need it to forge mental connections. I learned as a very little kid that you don’t try to kill a bee with your bare hand after only one trial. I might also wrongly conclude that it’s wise to throw money at slot machines if I happen to win on my first attempt but if I do it another thousand times and never again experience such luck, I will be more properly trained.

B. F. Skinner’s work with lab animals in “Skinner boxes” showcased this and it is learned by endless waves of psych students. Critters in the boxes had things they could do (pushing levers, for instance) with all sorts of consequences, like getting bits of food. Behaviors followed by positive outcomes (or abating negative ones) eventually get performed more frequently and behaviors followed by unwanted outcomes diminish.

Many of the jobs people occupy, rads included, aren’t all that different from the “Skinner box.” We’re not necessarily confined to a small space (although I suppose that depends on your reading room), but we are in a fairly controlled environment. A bunch of stimuli come our way, we react, and the experience shapes our future behavior.

Once upon a time in this column, for instance, I wrote about a poorly thought-out system in a “seven days on, seven days off” job I held. Whenever a rad logged in for a shift, if she or she accrued any alleged QA “misses,” a tab at the top of the RIS window would be colored red to indicate there were cases needing to be reviewed.

I have never met a single rad who enjoyed receiving such news: Here’s a claim that you screwed up, and now you have to click on it to find out how badly you messed up. The best-case scenario is that it is nonsense, but you still have to defend yourself, hoping the judges see things your way. The worst case is that you actually erred, and somebody’s health care suffered for it. Meanwhile, you’re dealing with this instead of reading cases for the RVUs that will generate your next paycheck.

Accordingly, every time you log in for a shift and see that little red tab, it’s aversive conditioning, a little punishment for showing up to your job. Plus, if you’re seven days on, seven days off, every time you come back from a week off, there have been that many more days during which QA cases might have accumulated for you. Multiply this effect over the course of the 182 days you’re working each year, and it adds up. The same can be said if there’s any kind of internal messenger system that accumulates unpleasant notifications or “to do” items for you, waiting for your next log-in.

A typical radiologist has plenty of opportunity for repetitive stimulus/response training. Suppose you read a hundred cases per day, and it irks you when you get cases without a proper clinical history. Let’s be charitable and say that only happens 20 percent of the time. That is still 20 times per day you get aggravated in exchange for opening a case.

Suppose you’re given outdated or otherwise glitchy software, and cases intermittently don’t load properly, or you have to reboot your machine to get on with your work. Ultrasound techs routinely fail to upload their “worksheets,” preventing you from reading out their cases while you reach out to your support staff to nag for the documentation. Computed tomography (CT) or MR techs have to be asked to upload missing sequences or reconstructions.

All of it boils down to the same thing: Opening a case has a decent chance to mini-punish you with a little jab at your morale. The best-case scenario is that the case opens without any problem, and you get to go on with your work.

It’s the same dynamic with interruptions when referrers want to get on the phone with you. Not only is your productivity taking a momentary hit, but odds are it’s not a call you’re going to be glad to receive. They think you got something wrong. They want to tell you something they should have included in their original “reason for exam,” and have you review the whole case with the new info in mind. There’s a relevant prior study nobody bothered to give you in the first place, so can you please reinterpret the whole scan?

Some of this stuff can be ameliorated if your rad group is willing to listen to dissatisfactions and implement policy changes to address them. However, most of it is just part of rad life. What can be done about it? We don’t want rads to build up resentment against their work, do we?

A behavioralist would look at how the pacing and timing of maladaptive stimuli/responses could be tweaked. Could some positive reinforcements be baked into the situation?

For instance, as I mentioned in this column a long time ago, what if your QA system wasn’t always pointing out your alleged screwups? What if, say, 50 or even 75 percent of the time you received a notification, it was to tell you what a great job you had done? Most of us have accuracy rates well into the upper 90 percentiles. That is a lot of good work going uncomplimented.

How about every time you received an interruption that stood to take away from your RVU productivity (assuming you’re in a job that hinges on such things), your system rewarded you with points for the time taken out from reading new cases? If you have to essentially reread an entire C/A/P cancer follow-up because a prior study is belatedly provided, you might feel a bit better about it when you get another C/A/P’s worth of productivity credit towards your quota/bonus.

If you want to see your group’s morale get a nice boost without having to rebuild it from the ground up, seriously think about consulting with someone who is psychologically savvy. I bet he or she would be able to give you half a dozen low-hanging fruit changes that you could beneficially make after just chatting with a few of your members.

(For what it’s worth, I have psych degree from an Ivy League university, and nearly specialized in psychiatry instead of rads. I’m available!)