Cherry picking: slowly I turned ...

In the 17th century, Colonial landowners on Maryland's Eastern Shore were plagued by wolves throughout the region. In hopes of stemming this infestation, officials of the fledgling government offered local hunters lucrative rewards for any wolf slaughtered. The right front paw and right jowl were required as proof of a kill. Rather than put in an honest day's labor, one enterprising young reprobate discovered where these parts were buried and made a small fortune simply by recycling them, thus carrying on a time-honored tradition of circumventing both public law and personal integrity.

It seems that radiologists not infrequently emulate the creativity of this loathsome cutpurse by gaming the relative value unit (RVU) system. It is said that New York Yankee star Joe Pepitone could recalculate his new batting average after a hit by the time he had reached first base. Some of us seem to possess a similar savantlike aptitude for determining which studies to read for maximum RVU impact, while leaving a worklist as picked over and dry as a week-old turkey carcass for our hapless colleagues.

Typically, neither the honor system nor direct efforts to stop this behavior have been effective. Cherry picking is not easily cured. Once that forbidden fruit is sampled, there is seldom a voluntary return to worklist integrity. Many enforcement policies amount to little more than "let the babies cheat."

Casino gambling security forces are ever vigilant for new and sophisticated cheating methods. It is quite easy to detect when the house is being hosed simply by looking at the statistically constant winning percentages table by table. It is likewise a simple matter to detect cherry picking in a radiology department. If more than 20 consecutive high-resolution chest CT studies remain on the worklist, this is as reliable a marker for cherry picking as a DNA sample.

I used to harbor only repugnance for these ineffable acts. In my former private practice, this was never a problem. One would no sooner think of cherry picking than showing up for work in sweatpants and a dirty T-shirt. Anyone consistently cheating his or her own partners would have been fired. Sadly, we seem to have passed into a different era. With larger groups and geographic dispersion, this practice is becoming more rampant. I know that one large teleradiology group has resorted to the use of anti-cherry-picking software to try to return fairness and responsibility to its practice.

As a radiologist trained in the 1970s, I have had to learn and adopt multiple new skills to stay current. Clinical MR scanning did not exist at the time of my residency. Real-time ultrasound, new CT applications, interventional techniques, and PET scanning have all been added as well. I believe I now need to re-examine my abhorrence of cherry picking and consider it a technique whose time has come. The term itself seems to have a negative connotation simply by the company it keeps. Those nit-picking administrators want even faster turnaround time. It's slim pickings in the fruit department after a spring freeze. Nose picking--no explanation needed or wanted. Is it any wonder that cherry picking has gotten an undeserved bad rap?

Consequently, I have decided finally to embrace this paradigm and join the ranks of the RVU mercenaries. In fact, I intend to pick the hell out of the worklist. Henceforth, I will read only outpatient abdomen and pelvis CT scans with a history of diffuse abdominal pain. I will no longer dictate any complex cases or any that offer meager RVU rewards. I have calculated (in little more time than it takes to run a 90-foot dash) that with my new workflow there is no reason to work more than several hours per day to meet minimum department productivity standards. The rest of my time can be spent in other pursuits--catching up on my reading or perhaps watching "Seinfeld" reruns on my iPod. I just wish my office were larger so I could practice my putting. Given these inducements, it won't bother me that my more honest colleagues will consider me a scheming, lying weasel.

Attention Residents: Cherry picking is a new skill that you must master during your residency to survive in the real world. Therefore I will devote several of my upcoming conferences to this topic. I will ask other radiologists with much more experience than I to join me and offer their expertise. We stand on the shoulders of giants. There are pioneers who have perfected the complex and arcane techniques involved in cheating their colleagues. Cherry picking falls under the ACGME competency category of "systems-based practice." Try to suspend your belief in the other competencies, particularly "professionalism," during these talks. Please make every effort to attend these sessions. I wouldn't be surprised to see an entire oral-board section devoted to the art and science of cherry picking in the near future.

The ability of our profession to rapidly adapt to changing reimbursement regulations is truly inspiring. I doff my cap in awestruck wonder, in worshipful astonishment, at the ferret-like cunning that has become emblematic of modern medical economics.

Dr. Weiss is the Clinical Section Head of Imaging Informatics, Geisinger Health System, Danville, PA. He is also a member of the editorial board of this journal.

David Weiss, MD

Some of us seem to possess a savantlike aptitude for determining which studies to read for maximum RVU impact, while leaving a worklist as picked over and dry as a week-old turkey carcass for our hapless colleagues.