Rock the Boat
Effecting change with diplomacy and determination.
Rocking the proverbial boat can be risky, especially when seas are rough. And few radiologists would dispute that their profession is in the midst of an all-out hurricane composed of reimbursement cuts, commodization, and uncertainty for the future.
To weather the perfect storm, imagers need to buck the status quo and begin to create change — large and small — within their own practices and across the specialty.
Bibb Allen Jr., MD, FACR, knows it's not easy to challenge comfortable, tried and true policies. Changes to established practices, habits, and processes can be a hard sell. But, to Allen, that's no reason to put off raising issues. "I think that we have to push for a culture that's different from the status quo," he says.
For many practices, the storm represents the shift from volume-based to value-based care. Despite the looming changes, many radiologists continue to focus on volume, reading more scans to compensate for cuts in the reimbursement that served them so well in the past. Meanwhile, a growing number of radiologists are looking to chart a new course, one that brings patient care to the forefront in order to transition to a value-based model and fight the commoditization that eats away at the role of the radiologist in patient care. "As we move from volume-based care to value-based care in imaging, a large number of radiologists are going to have a hard time letting go of the volume-based model. It's been very good to our specialty," says Allen.
Other radiologists are takin on more practice-specific issues, such as quality improvement projects, referring-physician engagement, or business management aspects. No matter the scope of the proposed change, new ideas often encounter resistance. The trick is to manage that resistance while finding ways to move forward.
When it comes to specialty-wide changes, Richard Duszak Jr., MD, FACR, chief medical officer of the Harvey L. Neiman Health Policy Institute, believes any meaningful results will come from boots-on-the-ground physicians. "If radiologists are going to bring about meaningful change, it's got to come from the grassroots level," he says. While those in leadership positions are perhaps best poised to implement changes, radiologists at all levels can spur positive transformation in their practices. "There's a difference between being in a formal leadership position and playing a leadership role," says Duszak. "Don't dismiss your ability to be a leader just because you're not a president or chair. Ultimately, a leader is somebody who is able to effect change. And you don't need a title to do that."
However, effecting change of the boat-rocking variety usually requires the approval of those who are in leadership positions. You don't want to capsize the boat, nor do you want your fellow sailors to toss you overboard.
There's a delicate balance between pushing for important changes and haranguing your colleagues into doing things they don't want to do. The following strategies can help to strike this balance.
Find an ally. Before launching a campaign for change, Duszak suggests approaching a leader who seems open to new ideas. "You've got to start somewhere and you have to pick the right partners. Don't try to convert everybody at one," he says. "Find the people who are most likely to listen. Just say, 'What do you think about this?'"
Start small. In the beginning, choose a project with a high probability of success and low probability of ruffling feathers. "You just need people to let you run with it," says Duszak. "And then it's up to you to make it a success." In Duszak's own practice, he chose to help champion RADPEER™ as a means for seasoned physicians to voluntarily participate in maintenance of certification. While there wasn't much initial enthusiasm for the idea, he and two others enrolled, explained the process to others, and even got the practice leadership to pay the fee for members who were interested. "All of the sudden people started thinking, 'Hmm, maybe that guy's not so crazy after all.'" With a little bit of idea capital built up, you can launch your next (maybe bigger) idea.
Reaffirm shared values. When presenting an idea, start with a higher-level value that you can all agree upon. An idea that contributes to better patient safety and care, for example, will be given more attention if it is framed as such from the beginning. "It can sound like this: 'I know we all agree that none of us wants the quality of care to suffer as a result of this initiative.' This phrase used early and often keeps everyone focused on the big picture, and not your objection," says Dike Drummond, MD, a family practice physician and medical career coach. "It states something no one can disagree with and keeps them from immediately disagreeing with you." Once you've done this, move to the specifics of your proposal.
Lead by example. Whether the change is big or small, you must first model the behavior before you can expect others to buy in. "Let them see what the differences are and they'll follow along," says Allen. A physician who wants to encourage colleagues to reach out to referring physicians will have more success if she picks up the phone or steps out of the reading room herself.
Keep at it. While we all wish change could come about quickly, the reality is that it sometimes takes a while and it usually takes persistence. Allen recalls his efforts to convince his hospital to participate in the Dose Index Registry®. "It really took almost a year," he says. "It was just accomplished by small things, like offering to help get it set up, stopping by to ask, 'Are you still thinking about radiation dose?' and reminding administrators of the value in being able to say that we're one of the safest places to get imaging done because we're paying attention to dose. And eventually, they said, 'Yes, we need to do this.'"
Duszak agrees that determination is key. "You have to say the same thing over and over as many times as you can cut and paste it," he says. The term Duszak prefers is "polite persistence." This type of persistence doesn't make enemies but it also perseveres in the face of obstacles. Duszak defines it as "really keeping one's eye on the ball for the long term. As long as you're moving slightly in the right direction, that needs to be the benchmark of success rather than rapid change."
Don't make it personal. "Just because people don't want to come on board doesn't mean that they're not good doctors or they don't care about doing the right thing," says Duszak. Don't let an answer of "no" change your relationship with a colleague, and don't let it discourage you from trying again in the future.
A thought-leader in business evolution, Debra E. Meyerson affirms the importance of believing in one's ideas and working to make them reality. However, at the same time, she advocates for balance: "If you push your agenda too hard, resentment builds against you. If you remain silent, resentment builds inside you."1
While finding that sweet spot may be a challenge, Duszak sees great value in examining the way we practice medicine and pushing for innovation. "We need physicians who step out of the box and really think about what we're doing," he says. "We need to ask, 'Are we serving our patients as well as we possibly can?'"
1. Meyerson DE. “Radical Change, the Quiet Way.” Harvard Business Review. October 2001:1.
By Lyndsee Cordes