Separating Mission-Critical Tasks from 'Stupid Stuff' and Perverse Incentives in Radiology

Think, for a moment, about someone you know who is completely satisfied career-wise, aside from universal stuff like wanting more money or maybe wanting to work fewer/kinder hours to get it. Perhaps “completely” was a big ask. Let’s aim for whoever’s closest to that 100 percent mark. I apologize if you or other rads you know are not even close to top of the list.

Thinking over who did come in first and others close to it, I have noticed a commonality: Whatever they wanted to be doing in their work, they get to do it most if not all of the time rather than getting diverted with other off-mission tasks. One of my best buds from internship had a blanket term for such things: “Stupid stuff.” (Physicians reading this might recall that they too did more than a little stupid stuff as interns.)

To the working individual, it’s not hard to tell whether one is engaged in stupid stuff or something worthwhile. One can feel it on a gut level. It’s also not too hard to convey the sentiment. If you were talking to someone about what you did for a living and then described some of your stupid stuff, chances are you would see them become puzzled at why you’re doing things irrelevant, even counterproductive, to your job’s actual purpose.

A diagnostic radiologist, for instance, might consider his or her primary function to interpret images and furnish helpful reports about them. Perhaps he or she is tailoring imaging protocols to specific clinical questions. Some radiologists may be taking on certain managerial or leadership roles to help make the rad group function better overall.

Alternatively, a rad might feel like he or she is engaging in stupid stuff when the rad is forced to use reporting templates that don’t match his or personal style or search pattern. Another stupid stuff scenario may occur when the rad regularly receives imaging studies that were done in a way he or she knows to be of less than diagnostic quality, and the rad has no power to fix the situation. For other rads, stupid stuff may involve regular adjustments to one’s reporting verbiage to defend against an overly punitive QA system or being a hypercritical QA reviewer so others will have as many “dings” on their records as the rad feels he or she unjustly receives.

Everybody’s definition of stupid stuff is going to vary based on what they believe their work should ideally be. One person’s mission critical tasks can be another’s complete waste of time.

However, there is a special flavor of stupid stuff that I think is more universally resented, assuming people recognize it. Sometimes, it can be subtle, the sort of thing you only gradually realize is occurring. Alternately, it may remain oblivious to until someone points it out to you one day and suddenly it is as if the person gave you the “red pill” from the Matrix. You were oblivious but now you see the unpleasant reality.

I am referring to perverse incentives. Perverse incentives in the workplace, from what I’ve seen and heard, seem to be most prevalent in fields with heavy bureaucracy. They seem to be particularly prevalent in governmental and regulatory gigs, but they also occur in academia. You’re dealing with a perverse incentive when you’re rewarded for bad behavior or punished for doing something good. This can be particularly damaging to morale if the punished “good” behavior is simply doing the job you’re supposed to do or if the rewarded “bad” behavior detracts from the mission.

Particularly bureaucratic swamps have entire jobs, even divisions, dedicated to perverse incentives. They may be necessary evils but that does not detract from their perversity. Suppose you are running a health-care system. You’re all about providing health care, right? Except you have folks in risk management who are providing no health care whatsoever but instead are focused on identifying and remediating (or removing) problematic folks in your system. Risk management has the perverse incentive of at least putting the brakes on some of those who could otherwise be providing health care.

Consider a common perverse incentive in radiology. We are all supposed to be productive and do our fair share to clean out the worklists with decent quality reporting. But what happens if there’s no reward for productivity, or even an occasional survey of who’s contributing what to the team effort? Some folks might conclude that all they’re getting for producing more RVUs is extra stress and increased malpractice liability, both of which are perverse disincentives. They can reduce both by turning down their efforts or taking more breaks for instance.

One example I have seen more than occasionally in those aforementioned bureaucratic places involves certain members of the team noticing impediments to their performance. They could use better tools, more personnel, etc. Leadership is notified and responds by instituting a new protocol. Staff are asked to fill out a new form (or webpage) on the issue every time they feel they are being held back. While it may take a couple of minutes to fill out the form, management can gather data on the situation, which may justify getting new hardware, software, people, etc.

Here is the problem. Workers who might turn to that form are already feeling hamstrung as they try to get their work done. Faced with the latest iteration of trouble, are they going to take the time to fill out and submit a form? Is it more likely they will shake their heads in frustration and use that precious time to get their job done? Plus, there may be a perception that submitting forms like this could get them labeled as troublemakers.

If you really want to get cynical, what is the chance that the leaders making this new policy know full well that this will happen? They can be on the record as having come up with this form idea to gather data for overall improvement of the team. Then, due to insufficient responses, they shrug and don’t have to change anything. They may surmise that it wasn’t that big an issue after all.

The best cure, of course, is prevention. Make sure you have people at the helm who understand the toxic nature of perverse incentives. Let them make it known to the rank and file that they are all about staying on mission. Anybody coming to them with observations or ideas about stupid stuff and perverse incentives will be given a hero’s welcome, fully listened to and invited to help fix whatever problems they have found.

This brings us back to my initial challenge. Thinking about the most satisfied folks you have known, how many of them work for themselves or are in positions of sufficient authority that they can correct most or all the of stupid stuff and perverse incentives that get in their way? Do you think there is a connection there?