Handling Work Volume: What Constitutes 'Speeding' for Radiologists?

I went on a little road trip this past weekend and spent about nine hours behind the wheel, which was more driving than I typically do in an entire month. I don’t get out much, given that I work from a teleradiology home office, not to mention the pandemic causing intermittent societal shutdown.

Long before COVID-19 entered the equation, I noticed an impact of the tele-lifestyle on my driving habits: I was far less hurried whenever I was on the road. No longer spending 50 to 60 minutes per day in a rush to and from work, I found what time I did spend behind the wheel was a much more laid-back, even relaxing affair.

In retrospect, the “gotta get there faster” feeling from my commute had infiltrated my standard driving mindset no matter where I was going. Removing the commute gradually fixed that. In the ensuing decade, I’ve mostly had to exert more effort to keep up with the speed limit rather than stay below it. Put me on a multi-state trek like this recent one, however, and I soon rediscover the gas pedal.

Regardless of whether I’m close to home and doing 40 on a 50 mph road or a couple-hundred miles away on an interstate highway, doing 75 in a 65 mph zone, I’ve noticed a commonality. As the great George Carlin once observed, anybody driving faster than me is a maniac, and anybody going slower is an idiot.

I have noticed this is not all that different from a lot of radiologists’ attitudes regarding work volumes. I read at a reasonable pace but that guy who goes slower than me is lazy. Alternately, I work pretty hard but my coworker burns through the work list way too fast to be doing a good job.

Every rad group, intentionally or not, has policies impacting the working speed of its employees. One determining factor is that all the work needs to get done, and it’s probably a good idea to reward those who do more of it. Another determining factor may be the notion that it is possible to burn through cases at such a pace that you’re no longer doing good work. I have seen groups stack all of their chips on either factor but most form a spectrum in between.

At the extreme end is pure “eat what you kill” pay-per-click compensation that rewards one for going faster. The only limit, per se, might be if you make a bunch of blunders that catch up with you at QA to the point where leadership taps you on the shoulder. Subsequently, you either slow down to improve or get canned, or you get sued into oblivion via medical malpractice.

The other extreme end of the spectrum might be a conventional flat salary gig in which nobody seems to pay attention to who does how much work. Under those circumstances, going as slow as possible could work in your favor. After all, you’re getting paid the same no matter what you do, and every case you read offers another iota of malpractice lawsuit risk, so why stress yourself?

Any number of mechanisms can fine-tune a group’s position in the spectrum. When I started doing telerad, for instance, my employer had a system wherein productivity-based pay dropped off at higher volumes. You still got paid per case and there was no hard “cap.” However, additional cases above a certain threshold were worth a few bucks less. There was more than one reason for this but for the purpose of this column, it made sense. This was a soft “speed limit” to disincentivize reading beyond a pace that many might consider unsafe or at least conducive to suboptimal work quality.

What constitutes “speeding” for a rad isn’t as readily defined as it is with motor vehicles. On the road, signs clearly display the upper (and sometimes lower) limits of what you should be doing. Disobey and you risk fines, points on your license, or worse.

In our field, there’s a recognition that everybody is different. What might be an unsafe working speed for one rad could be a typical day, or even slow or boring for another. Then there is the matter of environment and infrastructure. If you’re given a highly efficient workstation, a list of studies you’re good at reading, and a sequestered workspace where you won’t be disturbed, you have everything you need to go faster than a rad with a crummy PACS that frequently crashes, exams outside of his or her comfort zone, and a constant parade of clinicians, techs, and other rads knocking at the door and ringing the phone.

That said, our roadway system for speed limits seems overly simplistic. Of course, some drivers are more capable than others. Similarly, some vehicles are more reliably handled at higher velocity, are better equipped for safety in case of accident, etc. Plus, there are differences in driving conditions such as time of day/night, weather, who else is on the road, etc.

But a speed limit somehow gets determined for each road and it applies to everybody. I guess there’s really no other logistically sensible way to do it. Even if there were, our society likes to believe that everybody should abide by the same rules no matter how frequently that fails to be the case. If you merely suggested that someone with a better/safer car and proven superior driving skills should be allowed to go faster than others, you would probably get tarred and feathered for being an elitist.

I wonder how long it will be before some politico or other grandstander in the social arena decides to make this his or her cause celebre. “We need to rein in these doctors! They get paid for each case they do. What is to stop them from going too fast and risking patients’ lives? The rest of society lives with reasonable speed limits because we know that driving too fast is dangerous. Why shouldn’t doctors have to live with the same rules we do?”

Probably the only reason it hasn’t happened already is that the whole fee-for-service system — and its “death by a thousand cuts” whittling away at reimbursements — depends on the notion that we can work a little more, a little harder, a little faster, to make up for each time radiology’s RVUs get hacked at. Take that away and the current radiologist shortage will look like a glut compared to what happens next.