Big Radfish in Small RVU Ponds: You Have No Idea What You Are Capable Of

If you spend much time at all with radiology social media, you come to recognize certain recurring themes. One pertains to how much work a rad can or should be able to do, which is often expressed in terms of relative value units (RVUs) per hour, shift, or year.

Sometimes it is a rad wondering whether he or she should take a prospective job with expectations of a certain volume of work … or a productivity incentive that hinges on how much a rad does. Occasionally it’s a group looking to rejigger their expectations for team members or come up with terms for hiring someone new.

Whatever the case, the question is usually how many RVUs would be realistic and/or reasonable. Sometimes it’s not even initiated as a question: Someone posts a job offering with RVU targets, and the responses include folks griping that the numbers are too high (or marveling that they are so low).

I have never been too inclined to take a poke at someone else’s numbers in that venue. No two people are alike. Sure, work ethics and scruples play are factors to consider. If you have two rads in the same situation but one is doing twice as much work, one might be lazy or the other might be a go-getter. One might be doing a thorough deliberate job, or the other might be a careless speed demon.

There is also room for personal strengths and weaknesses. If one rad is a musculoskeletal maven and the other is a body imager, and you plunk them into an orthopedic facility, guess who is going to shine? Transplant them into cancer care, and things might change.

With the passage of time, I have had even more reason to understand that there is no comparing of numbers, not with other rads, and not even against my past or future self.

Let me take a step back, a giant one, to my childhood. As young lads, my brother and I were occasionally advised that we were big fish in a small pond. This was in terms of academics. Our public school was not full of superstars, in part because a lot of local families with means sent their kids to private institutions. The resulting “brain drain” made it pretty easy to cruise along at the top of the class.

Then I went to an Ivy League college, a much larger pond in which I wasn’t such a big fish. It didn’t matter how much I had been forewarned. I proceeded to study just as little as I had previously and was rewarded with mediocre grades. As a result, getting into med school was far less of a “gimme” than getting into the Ivy League college had been. But then the med school I got into, once again, was a comparatively small pond.

I was convinced I had learned my lesson and would always remember the importance of the fish/pond ratio. Even in my new, smaller pond, I hit the books hard, made sure to score high on my United States Medical Licensing Examination (USMLE), etc.

There is a funny thing about such lessons. The more convinced you are that you have completely learned them, the more determined life seems to find ways of showing you haven’t. I definitely learned the folly of comparing fish from different ponds against one another (at least until they wound up in the same body of water). However, it wasn’t until I had worked in a couple of different radiology groups before I started to understand that I shouldn’t even compare myself in pond A against how I might be in pond B.

In my last on-site job, for instance, where I had plenty of interruptions and distractions, a good day’s work for me was 60 to 80 mixed cases. I knew that stacked up well against the other rads there, even those whose roles allowed them to work more undisturbed. I came to conclude that this was a reasonable case volume.

Moving into my first tele gig, I was good and nervous. I knew the average rad there did more than 60 to 80 cases in a shift, and if I didn’t improve, I would be giving myself a pay cut. I hoped that the lack of interruptions would be enough to boost me to a more profitable level and I knew that the telerad company’s infrastructure (software, hardware, support personnel, etc.) would help.

Sure enough, the next few years saw my daily volumes climb to newer heights. I knew at some level that it wasn’t all because of my personal capability but it was gratifying, and I probably gave myself more credit than I should have. My idea of “a good day’s work” went from 60 to 80 cases to 100, even 200 (more when I got a bunch of x-rays, but that’s another story).

When I moved on to another telerad outfit with far less of an infrastructure, my numbers tumbled. It was humbling but with some time and introspection, I was able to adapt and accept that the new situation wasn’t a deficiency on my part. I was just in a pond that didn’t allow for the same performance I had enjoyed before. When I moved on from there into yet another group with a different infrastructure, it was time to adapt yet again.

It was only then that I finally found myself in an RVU-based situation. Everywhere else, I had counted in terms of case numbers, “work units” unique to a given employer, etc. I had tried to get a notion of what my RVUs were in earlier jobs, but there was really no straightforward comparison.

Looking back over these various ponds, it’s easy for me to see that I have been relatively the same-sized radfish all along but maybe with some gradual, long-term growth as one might expect in a career. The best way to judge has been against other rads sharing the same infrastructure with me. I tend to be in the same percentile of a group of 400 rads with the best-oiled telerad machine as I am when I am in a group of a dozen in a “work in progress” startup.

But what if I am sizing up a prospective new gig? I have no real idea of what I might do there, and I would advise readers in such a position to take the same attitude. Unless I can somehow go and sit in the new place’s reading room and test out working for a couple of weeks — or have them send me the home workstation I would be using remotely — I can’t really know what the case mix will be like. I won’t know how well their software suite will mesh into a functional unit or how much their voice recognition will help or hinder. Pretty much any aspect of a new rad job can have an impact, positive or negative, and it might just take a leap of faith to find out.