The Antifragile Radiologist.

Radiologists work in an unpredictable world. Reflecting on the coronavirus disease of 2019 (COVID-19) pandemic provides a pressing example. To be resilient, we must adapt to an ever-changing health care environment. Resiliency allows one to survive challenges without failure or decline. What if it were possible to benefit from uncertainty and become stronger because of it? This is the question Nassim Taleb addresses in his book, Antifragile: Things That Gain From Disorder [1Taleb N. Antifragile: things that gain from disorder. Random House, New York, NY2012Google Scholar]. He defines antifragility as growth through hardship; it allows people to thrive in an uncertain world. We offer a few antifragile strategies radiologists may utilize to better handle unpredictability and benefit from the volatility of an ever-changing profession. Do not “misread the past to predict the future.” The methods we use to predict the future may falter and ruin our plans. Medicine uniquely has a predictable career trajectory. At each stage along this trajectory, we are planning for the next step. The medical student is planning for residency, the resident is planning for fellowship, and so on. Although planning is important, we must normalize unpredictability and surprises (named “black swans” by Taleb). Black swans may define our future and alter our current predictions. Consider the COVID-19 pandemic. This was a black swan that derailed many physicians’ plans. Normalizing unpredictability may allow us to take the first step in becoming antifragile in medicine. Balance risk utilizing the barbell strategy. The barbell represents a risk distribution. Taleb recommends risk aversion on one end and risk loving on the other. Consider a hypothetical radiology group practice. It begins by contracting with a hospital. This embodies the risk-averse aspect of the barbell. The contract encompasses 90% of the practice and provides reliable, low-risk business. Although the hospital contract is risk averse, allocating a small number of resources to high-risk but high-reward growth opportunities may provide significant benefit, with minimal downside. These opportunities may include expansion into other markets, investment in a new outpatient imaging center, or starting a side hustle. There are many examples of physician side hustles that may encompass the risk-loving side of the barbell. Radiologists are highly skilled professionals with advanced expertise. Harnessing the potential of the Internet and sharing these skills by starting a blog or YouTube channel, creating an online course, or establishing a medical-legal consultation business are just a few ways to begin a side hustle. Numerous physicians have launched very successful businesses from what started as small side hustles. Focusing 10% of one’s time on an enjoyable side hustle may eventually reap significant reward while hedging against unpredictable outcomes. Grow with your mistakes. Errors can be an investment; they provide vital information on how to improve. View mistakes as learning opportunities. Observe what went wrong and intentionally make corrections. This fits into the idea of “just culture,” which is the opposite of blame culture. In just culture, mistakes are considered the result of a faulty process, rather than a specific person. View mistakes as an opportunity to improve the organization, not penalize the individual. In radiology, mistakes are inevitable. There is no radiologist who has not at some point missed a potentially significant finding. To become antifragile, expand your optionality. Optionality means having choices available for which you have the right, but not the obligation, to act upon. Having options allows for better responsiveness to unforeseen circumstances such as burnout. Fifty-five percent of radiology practice leaders reported burnout as a “very significant problem” [2Parikh J.R. Wolfman D. Bender C.E. Arleo E. Radiologist burnout according to surveyed radiology practice leaders.J Am Coll Radiol. 2020; 17: 78-81Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. One way to decrease burnout is to emphasize financial literacy. Radiologists that achieve financial independence earlier in their careers increase their options to cope with potential burnout. Financial independence allows the option, but not the obligation, to work part-time, change practice type or location, or even retire early. Although you may not exercise any of these options, just knowing that you have these options makes you more antifragile. Utilize redundancy to enhance antifragility. Systems may benefit by implementing a “redundancy buffer.” Although redundancy seems to reduce efficiency, it may allow better handling of stressors and unexpected challenges such as the postpandemic surge in clinical volumes. For example, redundancy may address the problem of short staffing. Departments often have overlapping skills that can be combined to address staff shortages. Emergency and abdominal radiologists may combine their shared expertise to add a layer of redundancy to handle increased volume. Additionally, adding incentive for part-time radiologists could add additional redundancy. A part-time radiologist may be incentivized to work additional shifts in times of short staffing. Theories and narratives do not always line up with reality. Antifragility embodies practice over theory. Discoveries are often derived by accident. They are found by tinkering, by trial and error, and through practice, not necessarily theory. There have been numerous medical discoveries made in this way, for example, the development of angioplasty. Charles Dotter, MD, the “father” of interventional radiology incidentally developed angioplasty when he mistakenly jammed his catheter through an arterial obstruction. He accidentally discovered a new way to dislodge arterial thrombi and thus pioneered percutaneous transluminal angioplasty [3Payne M.M. Charles Theodore Dotter: the father of intervention.Tex Heart Inst J. 2001; 28: 28-38PubMed Google Scholar]. Dr Dotter was a lifelong “tinkerer” who embraced the process of trial and error and in the process founded an entirely new field in medicine. Results-driven research may fall short as discoveries do not align with initial expectations. Instead of quitting when results are unexpected, embrace unplanned results and continue tinkering and practicing. Radiologists are constantly barraged with information. There are innumerable journal articles published every month. Information in the medical field expands at an exponential rate. Learn to discern signal from noise among this information. Do not overreact to noise while missing the signals. Although new information is important, it is not all relevant. Prioritize information that is applicable and hone down what you consume. Consider reading two articles a week, prioritizing personally relevant information. A specific strategy used by the authors for noise reduction involves the use of Electronic Table of Contents (eTOC) Alerts. Start by setting up eTOC alerts for a select handful of relevant journals to your specialty while unsubscribing from irrelevant publications. eTOC alerts will now provide you a bird’s-eye view of relevant updates from which you may select a small number of articles for keeping up with advances that may be relevant to your practice. Cut down on the noise and become more conscientious of the signal. Antifragility is often about what you avoid, more so than what you seek out. Focus is about saying yes to what you are working on and no to everything else. Subtractive thinking can solve complicated problems. Simple solutions often have large impact. A less-is-more heuristic can be useful when making decisions. Using this heuristic, only one compelling reason should be used to make choices. If multiple reasons are required to justify an action, perhaps it is not worth pursuing. Consider a radiologist who is contemplating a new job. The radiologist is 15 years out of training, now unsatisfied with his or her current position. When looking for new opportunities, the radiologist consider factors including location, salary, proximity to family, and so on. Compared with the radiologist’s current position, some opportunities provide a minor incremental improvement. If the goal is to make a significant career transition, be patient and wait to find an offer you cannot refuse. In this way, numerous increments are replaced by one large step. The ethics of antifragility should be considered. Some individuals and institutions can be antifragile at the expense of others. Benefitting at other’s expense is an ethical concern that should be avoided. The solution to this dilemma is having “skin in the game.” This means you are personally affected by your decisions and actions. Radiology partners in private practice may provide an example. When partners have skin in the game (ie, practice ownership), individual success leads to collective growth and benefit for the practice. Salaried employees, comparatively, may not share the same motivation; their actions are not tied to the practice’s success. Partners with skin in the game are motivated to do what is best for the practice because personal failure will lead to collective consequences and vice versa. Antifragility can be a valuable tool to help radiologists grow through challenges and become stronger in lieu of unpredictable changes. The strategies discussed here provide a framework for understanding antifragility and how it may be practically applied. Resiliency alone allows us to survive unexpected change, however, by normalizing unpredictability and utilizing antifragility, we can come out stronger.