The Theoretically Free Radiologist

Another big election has come and gone. In the increasingly brief respite we can enjoy before the next rounds of campaigning begin, there is room for some conjecture (and hope or dread) of what this round of winners will bring about.

One theme is disruption of the status quo. A lot of maladaptive things have been built up, and it’s proposed or planned that they be torn down and replaced by better stuff.

The scope of it all can be too massive to grasp. One might bring things down to subjective Earth with thoughts like “How might this affect my profession, or me personally?” Pragmatism also demands such inquiries.

A lot of folks in health care, rads included, could rattle off laundry lists of what they would like to see scrapped without the need for replacements. We all have ideas about how we could function better if not for a host of rules, regs, policies, mandates, overseeing entities, etc. We are simultaneously held back from doing all we know we could and forced to waste endless resources on empty-gesture tasks instead.

Spend a few years, let alone a decade or two, working under such conditions, and you have more than a few fantasies about how you would do things properly if all bureaucratic fetters were cast off. That can be anything from dreaming of not having to dictate contrast dosages into your CT reports to ditching “nuisance CME” requirements for state licensure that have nothing to do with your line of work.

Every now and then, however, I find myself wondering just how many of us would handle it if we suddenly found ourselves as “free” as we have been wishing.

We didn’t get into this situation overnight, lest that need saying. The health-care frog has been boiled very slowly over a course of decades. Along the way, some folks surely tried sounding the alarm that it was time to jump out of the increasingly hot water, but no exodus occurred.

If you would like a good example and have time on your hands, do a little reading on how docs went from working like any other professional (determining their own rates) to being captives of third-party payors, most importantly the government.

When this becomes a long-term situation, in which successive generations come and go without knowing of any other system, it becomes a matter of “That’s just the way things are.” Talk about doing things differently and you are charitably considered an idealist or less kindly dismissed as a crackpot, even a troublemaker (throw in the word “dangerous” if you like, since that seems to be the in-vogue tar brush for anything politically unfavorable nowadays).

It is hard to break out of that kind of thinking, so hard, in fact, that if suddenly free to do things in any way at all, one might have no other ideas about how to proceed. It is like having a bunch of domesticated livestock and deciding you are going to open the barn doors and let them all return to the wild. They might not be all that inclined to go. If you force them, they might not survive.

Docs en masse might not go bankrupt, but as a group, we are pretty notorious for having poor business sense. I think only a very small percentage would do well right out of the gate. Many more would eventually find their footing, but only after struggling for a while and possibly falling on their faces.

I suspect a lot would sell themselves short (“I don’t want to be greedy”), and barely cover their costs, including retaining their employees. Some others would surely reach for the stars, overextend, and crash/burn. Many would trade one set of masters (government, regulators, insurers) for another (hospitals, multispecialty groups). “Just let me do my job. You take care of the logistical stuff.”

We wouldn’t do any better with the non-financial stuff. I have hypothesized before about what would happen if our dysfunctional system of malpractice law were to suddenly vanish. Congratulations, doctors, you’re free to practice medicine as you see fit without fear of being dragged sideways through a medicolegal nightmare that might end with confiscating everything you own and terminating your career! For the sake of completeness, let us say bad QA systems go away too.

My projection is that no drastic changes would occur. At first, you might not be able to tell any difference at all. Most of us don’t hedge or otherwise practice defensive medicine because we are actively thinking, “I had better do this because I might get sued if I do that.” The vast majority of this behavior comes about after many years of doing exactly the same thing. It would take some serious unlearning and relearning to do anything differently.

I reiterate that this is generational. Current docs have only known a world where medical practice is warped by legal considerations, and that includes being educated and trained by other docs with the same experience. Even our mentors’ mentors might never have known otherwise. A lot of the “best practices” we consider to be the undisputed way things ought to be are rooted in this foundation. That is not likely to suddenly change if the medicolegal landscape overturns.

All of this isn’t to argue against the need for changes, even drastic ones. Doubling down on bad practices because that is all you have known makes no sense at all. Neither does nibbling around their edges with token gestures that won’t have any meaningful impact. But any changes that do get made will hopefully allow for people, especially docs who’ve been doing things a certain way for decades, to adapt slowly and get a sense of buy-in.