Tag: workload

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The Last Case Bolus Phenomenon!

bolus phenomenon

Ever notice that the end of a shift tends to have a bolus of cases? Just as you are allowed to leave the building, you find yourself with multiple studies that you need to read emergently. Usually, they are more complicated, and you don’t leave your station near when you are “supposed to be” finished. Well, this bolus phenomenon is not by any means random. Based on logic and my experiences, there is much more to this phenomenon. So, let’s go through some of the causes why you suddenly experience more cases that can often be the most difficult ones right at the end of your shift. You may be surprised at the reasons!

Transitions Are Not Smooth

Down in the emergency department, just like in radiology, no one wants to leave over work for the next ER attending shift. So, they will often order a bolus of cases so that the next physician does not have to write for them. This process causes a sudden cluster of studies in the radiology department. And, at this point, toward the end of your shift, you also feel the heat.

The ER Doctor Likes Your Work

Here is some good news/bad news for you. Guess what. Sure it’s great that the ER physician downstairs likes your dictations and diagnostic acumen. You have made a friend for life! However, that same phenomenon can lead to a bit of pain; right before your shift ends, they will try to get in as many patients as possible so that the physician downstairs will get all your dictations before the subsequent radiologist arrives. Sometimes, it does not pay to be the best!

ER Shifts End The Same Time As The Radiologist

Unfortunately, we like to begin and end shifts at typical times. Ten o’clock can be a standard time for physicians to leave. So, as the radiologist, you are not alone at that time. Therefore, you will receive the bolus of cases that need a disposition at the same time that you will leave. In this case, you can resolve this issue by changing the timing of shift changes so that they don’t coincide.

Transport Logjam

Ever take a gander outside the reading room, only to see ten patients in beds in line in the waiting area, waiting for their study. A lack of transporters can often cause this logjam. And, the same lineup often happens in reverse when they need to leave. These logistical issues often occur when your hospital does not pay enough to get these transporters to do their jobs. A hospital is only as good as its weakest link!

Pressure For Disposition, a Definite Cause For The Bolus Phenomenon

Finally, some emergency medicine physicians can become fickle. These emergency medicine physicians delay and protract until they finally decide what to do. And they must make this final decision before the end of their shift. To do so, they will probably need that definitive imaging study to confirm or refute their suspicions. So, these examinations culminate their thought processes right before they leave. You are there reading CT scans for them to reap the benefits!

The Last Case Bolus Phenomenon Is Not Random!

It feels painful to experience a large cluster of cases at the very end of your day, right before the end of your evening. However, contrary to what you might think, it is not a random process. Poor transitions, ER physician fans, problematic timing, transporters, and pressure for disposition, are all factors that often cause this bolus phenomenon. Some of these factors you can change and others not so much. It’s one of those hazards we experience when a shift is about to end. It’s just part of the job!

 

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Is Radiology Falling Apart Or Will It Continue To Thrive? I Need To Know!

radiology falling apart

Question Theme: Is Radiology Falling Apart?

Hi, thanks for doing this blog, it’s been an excellent resource for me as a medical student interested in radiology.

As a medical student, there is a lot about radiology as a field that appeals to me; the short “patients”, the diagnostic nature (you give your interpretation, and you finish w/ the patient), the fact that work doesn’t come home, the essence of medicine being radiology, the flexibility of the field in having non-medical interests, etc. However, as someone who wouldn’t be practicing for the next 7-8 years at least, and as someone who wants ideally to have a substantial long career, there are a couple of things that give me pause that I hope you can clear up.

1) I’ve heard a lot of conflicting thoughts about the radiology job market and the increasing “race to the bottom” for salaries along with w/ increases on workload. Can you comment at all on this and how you see the trends for several years out?

2) I have always leaned toward being a private practice physician. And, I know the direction across all specialties is increased consolidation (practices being bought out by hospitals, venture capitalists, etc.), but it seems like radiology is more prone to this than other fields. Do you see this trend holding for the near future?

3) Re: increasing workload; how flexible are practice options still? Is going to Hawaii or New Zealand for weeks at a time to do remote reads even feasible? What are the main practice options viable for a starting radiologist outside of being an academic/private radiologist?

4) In a similar vein, do you see radiology going down a comparable path to EM, where you have many shifts at odd times and holidays? With the push towards 24/7 coverage, I’ve heard rumors this could be the future of the field, and I do not like the schedules EM physicians have at all.

5) Finally, as more of a fun question, what are some of the most exciting things on the horizon for radiology as a field? I know we hear a lot about AI, but I’m assuming there’s more in the pipeline besides that. Perhaps any new modalities altogether? Or whatever else is exciting to you personally.

Thank you so much for helping out a “jaded” and burnt out M3! Continue being great!

 

Answers:

Great question(s). Each of these queries can be an entire blog! But, I will try to answer each of these in short order.

Will radiology be involved in the “race to the bottom” for income? Well, I do agree that over time, the workload has been ramping up due to increasing efficiencies created by technology. And, I see that trend continuing. However, the pattern will take a slightly different path. But, let me start with a little radiology history.

Initially, the first expansion of work for radiologists was multiple new modalities  (ultrasound, CT, and MRI.) Then, the next revolution was the PACs system and the digitization of images.  Now, we are about to experience a new generation of efficiency, that would be the software and AI revolution to assist you with your work. So, yes, you will be continuing to read more studies quicker. And, the government will not be adding new money into the system. Therefore, we will be much busier over time, and the money reimbursed per procedure will decline. However, with AI, it may not be “harder” to read these studies because AI will help you with things like triage, dictation, and detection. So, if you like technology and anatomy, radiology will still be the best field in medicine!

What about consolidation? Unfortunately, I believe that this trend will continue for a while. Economies of scale will continue to make larger better. What does that mean for you? You will more likely need to work for either a large private practice group, a corporate entity (i.e., large teleradiology company), or a large academic center. The days of 2-10 person private practices are slowly drifting away! (I was thinking about writing on this topic in an up and coming blog as well!)

How flexible are the options to practice? Well, here is where radiology takes the cake. Again, it depends on your debt load and your desire to work. But, all the options that you mentioned are still available. Hawaii and New Zealand are more than possible. And, you can work any number of days per week. Just like any other field, however, the less you work, the less you will make. So, you need a financial backstop if you want these options! If you desire a more atypical area to practice in radiology, that is available too. Try informatics if that suits you! Or, consultation work is possible. The sky is the limit in terms of flexibility!

Will radiology work turn into ER shift work? I believe you will have several choices and that it depends on how you choose to practice radiology. As I mentioned in the last paragraph, I think we will continue to see lots of options to decide how to practice. But, for many young graduates, you are right, some may be forced to do shift work depending on their debt level and where they want to live. But, by no means, will you have to do shift work. Clinicians wish for the presence of a physical radiologist in their hospitals. And, day time work will still be available.

What do I find exciting about radiology? That can also be an expansive answer. However, I am a nuclear radiologist, and I am fascinated by the new varieties of diagnostic radiopharmaceuticals coming down the pike for all sorts of diseases. Additionally, I see loads of new cancer treatments with new radiopharmaceuticals as well. Moreover, PET-CT and SPECT-CT  technologies are markedly improving, making visualization, and diagnosis more straightforward and quicker. In terms of other areas, MRI is a continually developing field with new sequences and contrast agents in numerous different fields (MSK, Breast, etc.) And, these technologies are expanding on top of an AI platform. So, is the future of radiologist exciting and bright? Certainly, yes!!! And, once again I can’t emphasize enough the answer to the theme of this letter, “Is Radiology Falling Apart?”, a firm no!

I hope this (briefly) answers and alleviates some of your questions and concerns,

Barry Julius, MD

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How Much Work Is Too Much For A Radiologist? (Think RVUs!)

RVUs

You are excited to start your career as a radiologist. And, you are interviewing, hoping to find a job where you can make the most money and pay off your student debt. There is much more to find the correct position than just assessing the income. Of course, you should consider the location and job profile. Just as importantly, however, you also need to figure into your calculations the workload and relative value units (RVUs) you need to complete to reach that income.

Avoid the following situation: an insurmountable daily imaging workload with a queue of patient studies that never ends. A job like this is bound to end badly. But, what is an unsafe workload for you, the radiologist? Or, more accurately, when looking for a job, how many studies are too much to read daily? Let’s investigate these issues together by examining some of the markers of workload and then get to some more specifics about the appropriate RVUs for an individual radiologist.

The Lowly RVU

Before we conclude how much work is too much, we first have to define a unit of work. The essential measurement of work is the RVU or relative value unit. According to an excellent presentation on the history of insurance, the first “RVU” came out in 1992 (1). It defined a relative value unit as three different components- physician work, practice expense, and malpractice. Most of the cost/workload of the RVU relates to physician work and practice expenses.

So, who decides the cost of an RVU? The American Medical Association defined a committee called the AMA Specialty Society Relative Value Update Committee (the RUC). It consists of an expert panel of an individual from the 21 major national specialty societies, two IM specialists, one primary care practitioner, one specialist, and six additional committee members. They assign explicitly what the Medicare costs are for each procedure. (1)

Why Is The Average RVUs Per Radiologist Is Important? (And Why It’s Not!)

OK. So, we have defined what makes an RVU and who creates an RVU for any given procedure. The following important question: What is the median number of RVUs per radiologist throughout the country. Well, I found a relatively recent article in The Reading Room that reports just that. (2) To summarize, it says that the average radiologist performed 10,020 RVUs in a 2020 survey. Now that we know the average RVUs per radiologist, it’s a relatively simple step to ask the average number of RVUs per radiologist per year in any given practice. Usually, the business or practice manager can obtain the number if you ask. If you find that the number deviates significantly from the mean, perhaps, you are looking at too few or too many studies.

But wait… There’s more to the equation! Let’s say you are a neuroradiologist that reads almost exclusively high-value RVU MRIs. Perhaps, you may read them significantly quicker than a general radiologist. Then, you can probably handle more RVUs than the average radiologist. Or, let’s say you just started and have not yet picked up speed with dictating. In that case, you will likely read lower amounts of RVUs. Therefore, you have to put in your weighted factor to determine how much work is reasonable.

Why Are Daily RVUs Even More Important?

Finally, we have developed your individual optimal yearly RVU number where you should lie within a reasonable spectrum. But, it is impossible to conform to that number precisely every day in any given practice. Some days you will have more studies and others less.

To add even more variation, in some practices, the radiologists may take 16 weeks of vacation, leaving only 36 weeks to complete all the work. To make the appropriate calculation of RVUs in this sort of practice, you would need to take the individual practice’s annual RVU number and divide it by the number of days per year worked. In actuality, that yearly average total RVU number does not measure the amount of daily work. A more appropriate calculation would be the daily RVU number. Therefore, a practice with a seemingly ordinary yearly RVU number can have an exceedingly high daily RVU number.

The RVU Tipping Point

What happens when a radiologist reaches the daily RVU tipping point beyond which they are comfortable? Well, most practicing radiologists have had bad days like this at some point. (Hopefully not every day!) You cut corners; your mind drifts elsewhere; burnout ensues; eye strain develops. Not only is it a wrong place for you, but it is also terrible for patient care. Let’s try to avoid that situation as much as possible.

How Much Is Too Much?

Back to the original question again. Too much work can vary widely for any individual. But at least, you now have a feel for calculating how much is too much. So, go forth and ask about the RVU number when you interview for a job, calculate the daily RVU value and compare it with your comfortable RVU numbers. That way, you are much more likely to find appropriate work for you!

(1) http://www.rsna.org

(2) https://thereadingroom.mrionline.com/2020/11/radiologist-alary-update-2020-show-me-the-money/