Where we are right now represents the culmination of choices we made in our lives up until this point. This is not to diminish the impact of those sometimes devastating events beyond our control, but to recognize it is how we chose to deal with those events once they occurred that shaped us. The same challenges that forge strength, character and leadership in some individuals will send others cowering into a corner—or perhaps out of a profession entirely. It is interesting that our lives are shaped not only by those pivotal major choices, but in the small patterns of choices we face every day in our lives and careers.

At some point you made the choice to work on the business side of radiology. Some people probably did so because they heard the income was good, some because it was a job that was open when they were looking and some were even asked to manage the practice by a radiologist. But no doubt for everyone, it seemed like an interesting choice at the time. Ironically, as a marketing person I went into radiology because I wouldn’t have to travel as much as I was working for a regional food company. It is ironic because I then spent more than 20 years traveling two or three weeks of the month.  Radiology also looked interesting (one of my relentless mind’s criteria for staying more than two years in any previous position without looking for something new to experience). I have never been bored in radiology—not even for an afternoon.

What are some of the critical choices we face in our noble profession?


We work in a profession where the business environment is largely out of our control and on many levels, sometimes almost nonsensical. And it’s getting worse, as those who do not work in healthcare try to “fix” things for those who do. We are at the mercy of physicians to send us patients, the hospitals where we provide services, the insurance companies who seem to pay based on arbitrary rates with equally arbitrary rules for determining what is payable. We have varying generational priorities among our employees and deal with at least one with marginal competence and an overinflated sense of entitlement. Based on the typical hierarchy of a radiology practice, we also work for multiple highly intelligent and frequently opinionated bosses who have minimal understanding of what our jobs entail. 

Are you a victim of these circumstances? Are you railing in frustration and lamenting the fact you have to constantly adapt to rigid rules and difficult situations? And that nobody knows (or cares) about the problems you face? And that no matter what you do to attain a level of control of your environment, someone else seems to be working overtime to muck it up?

While disorienting and demanding, that’s also a level of job security—at least to the degree there will be a challenging, frustrating, unending-stack-of-stuff-to-do position in radiology. Can you handle and even enjoy it?  You get to decide. You can choose victim or you can choose student, warrior, puzzle-solver, “practicing without a license” psychologist, arbitrator, negotiator or interpreter—and sometimes all of those in the same day! Granted you need a couple of checkpoints to maintain perspective:

  1. There was obviously nobody from radiology at the table when the group of idealists sat down to make new laws—and we have lots of “committee” regulations to contend with. This is stupid, but we need to play.
  2. My life is a test. What does not kill me makes me stronger.  If I can get through this I can get through almost anything. (Add other reassuring motivational quotes here). 
  3. Now that’s interesting. This happens at about the time you feel you’ve experienced every strange and screwed up situation that could ever occur.
  4. If this crisis was happening to someone else, would I think it was funny? This is valuable in situations such as preparing for a conference call with the labor board regarding the manager you fired for viewing porn on the company computers, when he thought he’d deleted everything (but didn’t) and said it was because you didn’t like him—and you’re uncomfortably assembling documentation.  (It happened).  

I chose to be an optimistic radiology warrior (with no apology to the “can’t we just group hug instead” ranks of my colleagues). I remain an optimist to the degree I think I can actually make a difference. As a practice manager, I arrived each day with my well-planned task list to greet the chaos of my chosen career. I worked quickly in spite of a myriad of interruptions by people and events determined to de-rail my progress. While they were often successful to some degree, as a warrior I continued on partly just to annoy them. I attempted gallantly to understand how someone with a college education and more than 25 years of experience could struggle with the inept instructions for filling out the latest new and improved series of 855 forms. Many days ended with a soul-draining 45 minutes of rush hour traffic—or airport screening and a packed flight, depending on the day. 

Are there bad days? Absolutely, especially when you just found out someone made a big billing error and you get to report on a monthly revenue dip at the next board meeting.There were days I was so beaten I want to run away to become a waitress in a small mountain town in Montana. After an especially bad day, I might wallow in misery for the entire evening—with the goal of diving deep into those feelings so they could all be done by morning. In the morning, it was time to be warrior again.

There are also the really good days when everything seems to go right. The new imaging center opened on schedule, the hospital CEO thanked you for identifying and helping to fix a big revenue leak, the practice’s board recognized your work with a bonus check or you find out the competition complained their best people are knocking on your door because your group has the reputation for being a great place to work. 

Running a practice isn’t a job for the faint of heart but you really do get to determine your attitude. And the right attitude is the key to success, longevity and satisfaction.

Taking Sides

This is one of the toughest and most treacherous choices. There will be radiologists in the group you like working with better than others. There are some you don’t like at all and even seeing their names pop up on e-mail stirs up a visceral reaction. There are also factions in the radiology group. You may personally agree with one faction more than another.  All of this is like gears in a complex machine and if you make a false step, the gears can crush you.

As a manager, your ultimate goal is to ensure the practice remains viable as a business—and you need to remind yourself of this on a regular basis so it can regulate your behavior and decisions. It frequently means running through the drill of how each faction (or shareholder) will react to certain situations and over time, you’ll get pretty good at predicting those reactions. It means asking yourself, “What’s the worst that could happen if we go in this direction?” and going through that exercise even when the decisions or directions seem innocuous. Even when you do this conscientiously, you will miss some.

Taking sides can be career fatal and even if you do everything in your power to remain neutral, you can be perceived as taking sides. If you are an administrative leader, you are viewed as the lieutenant of the senior members of the group—and in fact you serve in that capacity. As new physicians become partners, they do so with a vote and some opinions. If enough of them share the opinion there needs to be a physician leadership change, you may find it would have been a useful strategy to get to know them and make sure they know you. They need to know just because you said “no” to some of their excellent ideas, it was for a reason—like they were in violation of numerous Medicare regulations, which regularly negate imaginative business ideas—and not just because you didn’t like their ideas.

The message here is to pay attention to the gears, know that dynamics in the group will change and be aware of where you are at all times. Make the decision to ensure the financial viability of the business and keep that as your “true North” compass direction. Even then the subsequent decisions may be difficult but it’s easier than pinging back and forth between personalities and factions (which can occur anyway, but hopefully to a lesser degree). 

It’s best to start with the choice to be personality- and faction-neutral rather than fluctuating with personal inclinations. It’s also essential to remember a change in physician leadership can literally occur over night—or with one critical vote, evolving quickly from” great place to work” to dysfunctional.


Ethical choices are easier when there is a clear “violation of the law” consequence and in radiology, those are often thrust upon us as complex Medicare regulations. Radiologists, by their very scientific nature and native intellect, are quick to identify potential loopholes in new regulations so when in doubt, make sure you not only do your regulatory homework but have the contact information for a leading healthcare attorney at hand.

Perhaps the most frustrating ethical situations occur in imaging center marketing. You maintain strict guidelines for anti-kickback implications and gifts, only to watch the center down the street gain financially for handing out baseball tickets and gift cards for MRI referrals.  And the frustrating thing is they have been doing so for a decade without consequences. Do you do the right thing even if it hurts financially or join the competition in the mud?

How do you stand your ground when the physicians (innocently) ask “Why can’t we just do the same?”  Two answers have worked pretty well:

  1. It’s against the law. No matter how much I like you, I’m not willing to do time for you.

  2. Then as they ask how many radiologists are in fact doing time, you remind them of the more likely penalty scenario—exclusion from the Medicare program, which in effect ends their ability to practice medicine. This usually has a greater impact than discussing prison time, especially with early-career physicians.

Very honestly, it would probably be possible to violate some Medicare provisions without getting caught. On the other hand, it is difficult enough to conduct business without making an honest error and inadvertently being in violation—facing sometimes significant penalties for those errors. In my mind, it has never been worth trying to manipulate the system, bend the rules or hope nobody notices.

Over the years, it was easy to make the decision not to game the gray areas for short-term gain. It is more difficult remaining a diligent student of emerging regulations and knowing when a seemingly logical operational decision might have just violated one. Or knowing what to do if an error is uncovered. (Hint: ignoring it is not the best choice and see comment about having a great healthcare attorney on speed dial).

In our business lives, just as in our personal lives, each day brings dozens of choices with obvious, and less obvious, risks and rewards. We function in a highly regulated and frustrating business environment. You can’t change that, but you can decide whether to be a victim or a warrior. It’s the same job either way, but there are wide variations in the element of fun associated with the decision.  Here’s to the warriors! (And a quick hug to the group-hug folks—it’ll be OK).      

Patricia Kroken, MSN Healthcare Solutions Director of Education and Corporate Communications


Prior to joining MSN Healthcare Solutions as Director of Education and Corporate Communications, Pat Kroken had nearly 30 years of experience in radiology management as both a practice manager and consultant to radiology groups, billing companies, software vendors and hospital radiology departments.

Pat has had more than 200 articles published, is a regular contributor to the Radiology Business Management Association (RBMA) Bulletin and a frequent speaker on practice management topics. She served two terms as President of the RBMA, is Editorial Advisor for the national RBMA publication, The Bulletin, and represented the “business side of radiology” as RBMA Liaison to the Radiological Society of North America (RSNA) Associated Sciences Consortium for 7 years. 

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