Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy
■ Clinical Practice Management
■ Training & Education ■ Leadership

A Devilish Dilemma: Carrots or Sticks?

If your leadership decision has unintended negative consequences, how do you right the ship?

In his July 2016 editorial , Bruce J. Hillman, MD, editor-in-chief, describes a newly-introduced bimonthly JACR leadership column, "A Devilish Dilemma" by Frank J. Lexa, MD, MBA, of the Wharton School of Business and the Radiology Leadership Institute®, and David Fessel, MD, of the University of Michigan. The articles explore the challenges in successfully navigating the treacherous waters of real-world situations, pulling in experts from throughout radiology to weigh in.

The first dilemma hits close to home:

As department chair, you recently instituted RVU (Relative Value Unit) targets for staff radiologists. Since then, you have noticed a marked decline in attendance at clinical conferences and technologists have complained that many radiologists are less available to take their calls. What will you do in the short term to address this issue?

Thankfully, our department chair is not instituting RVU targets and is instead acting as a champion for radiologists in the face of institutional leadership RVU pressures.

The unintended consequences of instating RVU targets include a decline in participation in non-RVU-generating activity and potential deterioration in technologist-radiologist communication. In the column, four radiology leaders provide their responses. First is Thomas Grist, MD, from University of Wisconsin, who wants to "balance the tension between individual clinical productivity and the culture of teamwork" by pooling RVUs from individuals within a radiology department. Accountability would be at the level of section heads, who would assign non-RVU-generating section responsibilities.

Michael Brant-Zawadski, MD, at Hoag Neurosciences Institute, would keep the RVU targets but add customer satisfaction to performance metrics at both individual and group levels. This "withhold-from-salary stipend" would be contigent upon meeting or avoiding targets, an example of the latter being number of technologist complaints per radiologist.

Next, Dr. Cynthia S. Sherry, MD, at Texas Health Presbyterian Dallas would abolish the RVU targets because they "incentivize gaming behaviors" while neglecting "noninterpretive value-added behaviors" (i.e., activities that are important to clinical care and to the academic enterprise, but that typically count as non-productive time, such as conferences). She believes that leaders should be very clear about performance expectations by creating a climate of commitment to all facets of our work.

The most important numbers for any organization are unknown and unknowable. 

– W. Edwards Deming, the father of Total Quality Management

The final response comes from David M. Yousem, MD, MBA, at Johns Hopkins School of Medicine. He would meet not only with radiologists to see how they feel about the achievability of RVU targets, but also with those upset about "conference attendance or radiologists' responsiveness" to listen to their concerns. He would work toward group consensus. Finally, he would put the RVU initiative to a vote.

I am amazed at the range of responses even among a group of only four radiology leaders. Approaches appear to run the gamut from carrots (eliminating RVU targets) to sticks (withholding portions of salaries). But what is loud and clear from all four leaders is their commitment to incentivizing participation in activities that don't lead to RVU accrual.

Whether you are a leader in your department or not, you almost certainly have an opinion about the above ideas. Or maybe you can think of other possible solutions to the first Devilish Dilemma. Please share your thoughts in the comments below, on Engage (the ACR's new online member forum), in a letter to the editor, or by tweet about it to @JACRjournal.

Related Reading

Transition to Value: Signposts for Change

Maximizing Radiologist Productivity: The Panopticon Radiologist

Productivity Increases with Real-Time Monitoring: The Hawthorne Effect

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Wednesday, 24 April 2019

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