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What is Your Radiology Delta?


Amid a glut of unnecessary imaging requests, common worklist frustrations and perceptions from other clinicians that they can interpret medical images just as well, recognizing your role as a humble difference maker may provide the ultimate RVU for patients.

I am a RVU generator. It is not exactly how I envisioned my career shaping up. Sure, as a diagnostic radiologist, I expected much of my professional value to be expressible in terms of case volume. However, I also thought I would be doing substantial amounts of “on the clock” stuff away from the workstation, whether it was planning strategy, optimizing group efficiency, and even forming policy. In other words, there is an interest in “bigger picture” kinds of stuff.

There are various reasons why that hasn’t happened yet. In the meantime, if I want to philosophize about the greater meaning of my work, it’s going to be in terms of lives I have saved, improved, or at least prevented from getting worse as result of cases I have read.

In the abstract, this is not a hard concept to grasp. Rads can interpret some pretty complex imaging, to say nothing of how we manage when we are given less than ideal tools to work with (technically limited studies, poorly chosen protocols or even modalities for the clinical scenario, irrelevant/wrong/non-existent histories, etc.). Functioning as the “doctor’s doctor,” how could we not be doing important work?

Start trying to quantify it, though, and one rapidly gets brought back to Earth. Muddling through a typical worklist, it is very easy to wind up with a “how much of what I’m doing really makes a difference” feeling. Plow through a few dozen portable ICU chest images, for instance, endlessly describing a bunch of tubes and lines and how one can’t rule out edema on this one or pneumonia on that one. Heck, it seems like they order daily chest films in the ICU without waiting to see what we had to say about the previous films.

Maybe you do a lot of mammos and every so often, somebody publishes a study about how screening doesn’t have a statistical benefit on survival across the population. Perhaps you cover ERs, see trauma pan-scans on patients wrecking their ATVs and realize the same patients trashed their snowmobiles last winter. Did it matter that you identified their rib fractures last year when they just went out and broke some new ones now?

Then there’s the matter of rads not being the only ones looking at imaging studies. There is an assortment of jacks-of-all-trade (ER docs, PAs, NPs) glancing at X-rays, sonographers essentially giving prelims on their scans to whomever asks, and subspecialists like orthopedic surgeons or neurosurgeons proudly boasting that they read their subspecialty images better than we do. It is easy to come away with the sense that even if we didn’t make some key diagnosis (or rule it out), others would.

More than once in a blue moon, I’ve had the notion that, even with all this going on, even with the ever-increasing volume of unnecessary imaging that gets thrown our way to dilute things, there are times where we stand between good and bad outcomes. In our diagnostic rad roles, we have the chance to do what nobody else can or will. As an individual trying to distinguish himself, I may sometimes do what other rads wouldn’t.

Such moments, as rare as they might be in this sea of other factors, are our “delta.” It is the difference that we can make because of how we perform when we’re doing our thing.

Of course, we don’t knowwhen those moments are afoot. If I catch a non-obvious fracture, I don’t know until after the fact whether the ER staff noticed it or sent the patient home to follow up with their primary care doc. If I think I see a suspicious density on a mammo and suggest diagnostic workup or biopsy, I won’t know until afterward if I was sounding the alarm over something benign or malignant. Even if it was bad news, I would have to be omniscient to know whether I made a difference in the quality/quantity of that patient’s life. Maybe the tumor would have been slow growing and instead the patient dies earlier from complications of the chemotherapy that I helped make happen.

It’s only with a very indirect, been doing this for decades, instinctive kind of feel that I have come to sense what my delta might be. I try to underestimate it in order to keep myself humble and my expectations low.

For instance, I think it’s a reasonable hope that as I do my best work, perhaps there will be one case in 10 in which I might say something more helpfully than another rad might have (or refrain from saying something unhelpful). Meanwhile, if you take the population of rads as a whole, it seems safe to say that in at least one out of 10 cases, we produce better outcomes than some other doc would have (ER denizens and surgical subspecialists alike).

Of course, no matter who ultimately looks at a case, let’s keep in mind that an awful lot of imaging doesn’t contain actionable results relevant to the patient who got imaged. Either the imaging was a “fishing expedition,” it was the wrong type of study to order for the clinical interest, or no imaging was warranted in the first place. Assigning that a one in 10 probability might seem cynical to some but not to anybody whose worklists resemble those I have seen.

So, I’m looking at 10 percent for me versus other rads, 10 percent for rads versus other docs, and 10 percent for imaging studies overall. I can reasonably expect my delta to be at least one case in 10,000. My pace of reading cases has varied with the types of infrastructure offered by my last couple of jobs, but that translates to at least twice per year.

Does that seem rare? Of course, I’d like it to be greater, but I did set out intending to underestimate. Even going with two lives per year, that will turn out to be 34 since fellowship. Add another 20 for each decade I keep plugging away before I call it quits (or it gets called quits for me). That’s a few dozen folks who got to live longer and/or better purely because I was involved in their care.

I would consider that a decent accomplishment for my career.

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