A Note From A Non Diagnostic Colleague

[WildRivers]

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Hey Dx Rads friends -

I'm a radonc and I rely on radiologists to do my job. It is integral. I need your reports, your comments, helping me with tough cases.

I have noticed something last 5-7 years. The reads come back fast, but I don't see much critical thinking as I used to. It is narrative describing things, without the medical part - differential diagnosis, making a diagnosis (with room for hedging). I'm seeing 5cm tumors in open lung not commented upon. Have to ask after the fact to do comparison to something from the same PACS system that is obviously there. Something feels different to me - as the consumer of your reports. I feel like I have to re-review things and call often for corrections. Good reports used to stage patients with AJCC / TNM. I do a lot of SRS and after treatment after is "possible recurrence" - without discussion of ratio of edema to tumor or T1:T2 mismatch or anything to point us in the direction of RN or recurrence, etc. MRI prostates not highlighting the dominant nodules. I even write on the order the specific question I want answered and that doesn't happen. Of note, I've been in several locations during this time span (AZ, WA, MI - rural and Detroit suburbs). I can't even say one area is worse or better. I find specific ones who's reads I like, but often times because of the way the practice is set up, I can't say "please have so and so read my scans". If I had the time, I'd have a few major things every week to call them about to addend. I'm not kidding, a lung patient with 5cm tumor. I called, the guy was so embarrassed, I felt bad, I just said it happens, but I need an addendum. I was about to treat a patient with SRS, but the MRI looked bad. The report mentioned one met. I'm seeing lepto. NSG reviews with me - "don't SRS this, they have lepto". Called rads, same thing, apologies. There were 7 or so additional small mets we found, as well.

At times I get pretty upset, but I know how hard everyone is working in all of medicine, particularly dx rads.

Am I being too picky? Am I just having strings of bad luck?

Please don't think this as an attack. It's just becoming such an issue and I don't have the faith I used to any more. I know who goes into this field - it's typically the brightest and best. It just feels different, particularly the last few years.

 

[maxxor]

Hey Dx Rads friends -

I'm a radonc and I rely on radiologists to do my job. It is integral. I need your reports, your comments, helping me with tough cases.

I have noticed something last 5-7 years. The reads come back fast, but I don't see much critical thinking as I used to. It is narrative describing things, without the medical part - differential diagnosis, making a diagnosis (with room for hedging). I'm seeing 5cm tumors in open lung not commented upon. Have to ask after the fact to do comparison to something from the same PACS system that is obviously there. Something feels different to me - as the consumer of your reports. I feel like I have to re-review things and call often for corrections. Good reports used to stage patients with AJCC / TNM. I do a lot of SRS and after treatment after is "possible recurrence" - without discussion of ratio of edema to tumor or T1:T2 mismatch or anything to point us in the direction of RN or recurrence, etc. MRI prostates not highlighting the dominant nodules. I even write on the order the specific question I want answered and that doesn't happen. Of note, I've been in several locations during this time span (AZ, WA, MI - rural and Detroit suburbs). I can't even say one area is worse or better. I find specific ones who's reads I like, but often times because of the way the practice is set up, I can't say "please have so and so read my scans". If I had the time, I'd have a few major things every week to call them about to addend. I'm not kidding, a lung patient with 5cm tumor. I called, the guy was so embarrassed, I felt bad, I just said it happens, but I need an addendum. I was about to treat a patient with SRS, but the MRI looked bad. The report mentioned one met. I'm seeing lepto. NSG reviews with me - "don't SRS this, they have lepto". Called rads, same thing, apologies. There were 7 or so additional small mets we found, as well.

At times I get pretty upset, but I know how hard everyone is working in all of medicine, particularly dx rads.

Am I being too picky? Am I just having strings of bad luck?

Please don't think this as an attack. It's just becoming such an issue and I don't have the faith I used to any more. I know who goes into this field - it's typically the brightest and best. It just feels different, particularly the last few years.

It’s crushing volumes. Something has to give. Either you keep quality up and the list gets loooooong or you let quality drop and the TAT meets the metric.

 

[tomballunger]

At my residency, residents are now being trained more with the mindset to clear the list regardless of quality rather than critical thinking and how to produce a clinically useful report in a timely manner. Readouts with attendings have gone completely downhill in the past 2 years as attendings burnout /give in to list and tat pressure

 

[Radguy12]

Hey Dx Rads friends -

I'm a radonc and I rely on radiologists to do my job. It is integral. I need your reports, your comments, helping me with tough cases.

I have noticed something last 5-7 years. The reads come back fast, but I don't see much critical thinking as I used to. It is narrative describing things, without the medical part - differential diagnosis, making a diagnosis (with room for hedging). I'm seeing 5cm tumors in open lung not commented upon. Have to ask after the fact to do comparison to something from the same PACS system that is obviously there. Something feels different to me - as the consumer of your reports. I feel like I have to re-review things and call often for corrections. Good reports used to stage patients with AJCC / TNM. I do a lot of SRS and after treatment after is "possible recurrence" - without discussion of ratio of edema to tumor or T1:T2 mismatch or anything to point us in the direction of RN or recurrence, etc. MRI prostates not highlighting the dominant nodules. I even write on the order the specific question I want answered and that doesn't happen. Of note, I've been in several locations during this time span (AZ, WA, MI - rural and Detroit suburbs). I can't even say one area is worse or better. I find specific ones who's reads I like, but often times because of the way the practice is set up, I can't say "please have so and so read my scans". If I had the time, I'd have a few major things every week to call them about to addend. I'm not kidding, a lung patient with 5cm tumor. I called, the guy was so embarrassed, I felt bad, I just said it happens, but I need an addendum. I was about to treat a patient with SRS, but the MRI looked bad. The report mentioned one met. I'm seeing lepto. NSG reviews with me - "don't SRS this, they have lepto". Called rads, same thing, apologies. There were 7 or so additional small mets we found, as well.

At times I get pretty upset, but I know how hard everyone is working in all of medicine, particularly dx rads.

Am I being too picky? Am I just having strings of bad luck?

Please don't think this as an attack. It's just becoming such an issue and I don't have the faith I used to any more. I know who goes into this field - it's typically the brightest and best. It just feels different, particularly the last few years.

Lmaooo, how about you tell all your other clinical colleagues to actually think before ordering random non indicated studies or put proper indications or stop acting like they know how to read studies themselves and arguing with reads. If you think the quality of rads has gone down, you should look at it from our side. We see every patient in the hospital and every stupid non indicated exam with and clinical history. The quality of clinical practice has gone way down.

Although I'm sure youre the only one that doesn't order stupid studies and you actually know how read scans even though youve never actually read a study in your life. You should come sit in on a call shift and see the bs we have to deal with everyday.

 

[WildRivers]

Thank you for the response.

I have to order staging scans and folllow up scans based on guidelines. I’m not a diagnostic physician. I did receive helpful DMs from others explaining some of the issues and why I may see this issue.

But appreciate the kind and thoughtful response.

 

[irwarrior]

Imaging volume will likely continue to go up as the diagnostic certainty continues to improve with advanced imaging in the proper clinical context. Patients signs and symptoms do not have a direct correlation with pathologic conditions. If DR was asked to staff the ER or urgent care I wonder if the imaging volumes would increase even more. How do you send a patient with tachycardia and some chest pain home and history of cancer home and not get a CTA to rule out PE? It has become more and more standard of care to get advanced imaging. Over time blood assays such as high sensitivity troponin for CAD will become more prevalent. The volumes of imaging are not likely to go down and if anything will likely continue to increase. The number of imaging specialists has not increased to the point to meet the rise and so it is hard to improve efficiency and while at the same time maintain the degree of quality one was used to. Not to mention the imaging has become more complex. ie multiphase imaging at 0.6 mm collimation as well as increase in number of MRI sequences per body part. This is all increasing the complexity of interpreting advanced imaging. Given the ubiquitous nature of imaging patient now have far more priors than we may have had 10 or 15 years ago and to do a thorough job one has to review all of the priors. The complexity of imaging has also greatly increased and that includes things like prostate and rectal MRI as well as the various PET imaging such as for prostate or neuroendocrine. This along with the multiple changes in treatment whether it be radiation, ablations, y90 , surgical resections and interventional and surgical implants has made it harder for the DR trainee to keep up with all of these advancements.

 

[irwarrior]

The other thing I have seen more and more of is that some of these cases are presented at the hospital tumor board where radiology and pathology will both be present at alongside medical oncology, radiation oncology and surgery.

 

[colbgw02]

Hey Dx Rads friends -

I'm a radonc and I rely on radiologists to do my job. It is integral. I need your reports, your comments, helping me with tough cases.

I have noticed something last 5-7 years. The reads come back fast, but I don't see much critical thinking as I used to. It is narrative describing things, without the medical part - differential diagnosis, making a diagnosis (with room for hedging). I'm seeing 5cm tumors in open lung not commented upon. Have to ask after the fact to do comparison to something from the same PACS system that is obviously there. Something feels different to me - as the consumer of your reports. I feel like I have to re-review things and call often for corrections. Good reports used to stage patients with AJCC / TNM. I do a lot of SRS and after treatment after is "possible recurrence" - without discussion of ratio of edema to tumor or T1:T2 mismatch or anything to point us in the direction of RN or recurrence, etc. MRI prostates not highlighting the dominant nodules. I even write on the order the specific question I want answered and that doesn't happen. Of note, I've been in several locations during this time span (AZ, WA, MI - rural and Detroit suburbs). I can't even say one area is worse or better. I find specific ones who's reads I like, but often times because of the way the practice is set up, I can't say "please have so and so read my scans". If I had the time, I'd have a few major things every week to call them about to addend. I'm not kidding, a lung patient with 5cm tumor. I called, the guy was so embarrassed, I felt bad, I just said it happens, but I need an addendum. I was about to treat a patient with SRS, but the MRI looked bad. The report mentioned one met. I'm seeing lepto. NSG reviews with me - "don't SRS this, they have lepto". Called rads, same thing, apologies. There were 7 or so additional small mets we found, as well.

At times I get pretty upset, but I know how hard everyone is working in all of medicine, particularly dx rads.

Am I being too picky? Am I just having strings of bad luck?

Please don't think this as an attack. It's just becoming such an issue and I don't have the faith I used to any more. I know who goes into this field - it's typically the brightest and best. It just feels different, particularly the last few years.

In all sincerity, thank you for your post. We should all be able to bring these issues to each other respectfully, like I think you did. Specialization tends to divide us when we need to be united more so now than ever.

Ten years ago, Geoffrey Hinton--the "Godfather of AI"--erroneously predicated the demise of human radiologists. Unfortunately, that has had real-world impacts that is affecting patient care.

Specifically, a specialty that was already starting to see shortages in the labor side of the market was shunned by medical students, afraid that they would be unemployed long before they were ready to retire.

Accordingly, those shortages have been exacerbated, made worse by an already relatively aged work force. Also, there is no sign that the utilization of medical imaging will slow, made worse by our society's increasing reliance on mid-levels, who disproportionately order advanced imaging.

Personally, it's been something to behold. I struggled to find a good job early in my career. Today, I receive multiple unsolicited calls and texts from recruiters daily that I don't even bother to answer or read. Turnaround time used to be THE metric that would cause a group to lose a contract or a radiologist to lose his/her job. Nowadays, outpatient exams sit for days on end.

AI is making radiologists more efficient, but it's not a foregone conclusion that will pick up all of the slack in the system.

None of that helps your particular situation. Unfortunately, your predicament is a predictable outcome of not only the law of supply and demand, but also when people listen to dinguses who speak out of turn about subjects about which they're not adequately educated.

 

[LegendaryBibimbap]

I am one year out of fellowship. Let me tell you friends, the bar for quality is really ****ing low out here, I am genuinely shocked at how bad a lot of rad reads are.

I do not blame rad onc for being frustrated, I 99% of the time do not read the prior report and just look at the prior images because of how yappy and worthless the reports are becoming.

 

[SeisK]

I can't say "please have so and so read my scans"

You’re sure you can’t? If I was in your position I’d become aggressive with it. Include as frank comments in the indication that you’re ok waiting until so-and-so is on shift for their report. It may upset some rads but most won’t care.

 

[GadRads]

We don’t have this issue at my shop and some of us are fast readers. Maybe the rad who missed the 5 cm lung mass read an old study or just forgot to look at the lungs. But volumes are insane right now, and these things can happen to anyone.

 

[Melkor]

Interesting dilemma for the OP. Maybe rads perceived as good in the community can use this to start charging clinicians some additional fee per read, given the trend of declining reimbursements. That's what any other non medical field would do.

 

[Steve_Zissou]

I am one year out of fellowship. Let me tell you friends, the bar for quality is really ****ing low out here, I am genuinely shocked at how bad a lot of rad reads are.

I do not blame rad onc for being frustrated, I 99% of the time do not read the prior report and just look at the prior images because of how yappy and worthless the reports are becoming.

Still in residency but a lot of the local hospitals and PE reads that we see on priors are stunningly bad. Like what I would expect from a late first year resident, not from an attending. Massive misses, trash descriptions, wordiness without saying anything, etc.

 

[WildRivers]

Thanks everyone - it seems like there are other people noting similar issues and it seems due to workload.

I had a patient last week with advanced head neck cancer go to ED with CN palsy and facial numbness. MRI read as negative. There is a mass in the cavernous sinus. He went home. Now, can’t open eye and pupil blown. The week prior he had a CT scan and you can see it a little there, as well. All the symptoms written in the order. Had to send him back and he was admitted.

This week, hx of lung cancer. And brain mri done for post tx surveillance. 5 mets. None measured and not counted. I get when it’s innumerable. But, it’s 5. Maybe that’s just being picky. But a couple measurements or at least of index would be nice.

When you call and talk to people and discuss cases, clearly they are knowledgeable and very helpful clinically. They take their time to talk you through findings. And you get the sense that if they just had the time, the work would also be more enjoyable, as well.

I don’t really think of this as fixable with modern medicine. The other thing is all my work was subject to evaluation by other physicians - there would be plenty of flaws to find. That’s the other part - there’s a microscope on you guys.

 

[odyssey2]

With the workload and workforce being what they are currently, you have to choose between quality and speed. It's just the reality nowadays

 

[Kuratz]

Agree with most of what has been said.

Just echoing that the problem is volumes and expectations for rads to meet 24/7 demand for multiple complex imaging studies on almost every patient walking through the door. Scanners also running 24/7; wasnt uncommon to have to read complex inpatient MRIs or onc CTs overnight as both a fellow and at my old practice since that’s who gets scanned at 3 am when the ED cools off.

Reimbursement also not helping things. Itd be great if I could spend 30 minutes on every PET like in training but that’s nowhere near realistic with staffing and trying to maintain reasonable compensation.

Clinicians are also partly to blame for the decreasing quality for reads. Multiple times a day I get asked to stop what I’m doing to put out a stat read on some complex follow up study “because the patient has their appointment immediately following”. Then I have to return to my normal list that is backing up so I can meet other unrealistic turnaround times because those expectations are also extremely high. So their is white glove service expectations for turnaround times but how can we possibly both do that and also provide high quality reports? It’s honesty exhausting and stressful trying to move as fast as humanly possible to keep clinicians happy and not miss permanent things. This is aside from often reading some complex case where there is an obvious known diagnosis that has been treated but we get some throwaway history and no priors. Honestly why even have the rad try to say anything insightful on that, it can only make us look stupid.

Another big issue is that patients have access to their reports, and immediately at that. In my opinion a large reason why you are seeing a move towards “describing” and not “discussing” is because if I start opining on some lesion giving differentials and putting possible diagnoses in the impression, the patients tend to freak out and it’s now part of the visible medical record. I’m not sticking my neck out with specific diagnoses if ultimately it’s getting biopsied for definitive path anyway. It leads to feeling like we need to describe stuff and then simply boil things down to: biopsy, follow/treat, or ignore.

This current paradigm is exhausting and not fun having to crank at full speed all day every day but that is what the system demands of us and I don’t see it changing anytime soon. If anything will just get worse

 

[vm26]

I had a patient last week with advanced head neck cancer go to ED with CN palsy and facial numbness. MRI read as negative. There is a mass in the cavernous sinus. He went home. Now, can’t open eye and pupil blown. The week prior he had a CT scan and you can see it a little there, as well. All the symptoms written in the order. Had to send him back and he was admitted.

Not admitted? ENT/optho/neurosurgery signed off? Thats crazy given how low the bar is for admission. What did they say when you complained to them?

I am sorry for your patient but advanced imaging for a complex oncology case to evaluate for CN pathology is absolutely not an appropriate ED case.

 

[Radguy12]

Not admitted? ENT/optho/neurosurgery signed off? Thats crazy given how low the bar is for admission. What did they say when you complained to them?

I am sorry for your patient but advanced imaging for a complex oncology case to evaluate for CN pathology is absolutely not an appropriate ED case.

Yeah, this seems almost made up

 

[WildRivers]

Yeah, this seems almost made up

What do you do for a person with an acute loss of cranial nerve function and headache with recent cancer diagnosis ?

The first ED visit led to a discharge and outpatient imaging a week later. The second ED visit was another mri that was read as negative and essentially was considered malignerer. The third visit was after we called a radiologist and asked why this was missed and then admitted

Agree should have been admitted up front! ED said imaging was negative

Waiting on outcome of review

 

[vm26]

What do you do for a person with an acute loss of cranial nerve function and headache with recent cancer diagnosis ?

The first ED visit led to a discharge and outpatient imaging a week later. The second ED visit was another mri that was read as negative and essentially was considered malignerer. The third visit was after we called a radiologist and asked why this was missed and then admitted

Agree should have been admitted up front! ED said imaging was negative

Waiting on outcome of review

Let us know how the review goes. I am on our groups peer review committee so have an interest in these types of cases.

Alson I should have been more specific in my initial post: With the above clinical history, most places would use a high-resolution skull base MR protocol. If this was performed beyond the normal day shifts, good chance this exam may not be read by a neuro-rad or a rad accustomed to reading. Cranial nerves/skull base is beyond the comfort zone of most community rads, and very good chance pathology would be missed (particularly if covered by random tele-rad group). Throwing in high volume of ED shifts does not help, and even an experienced neuro-rad getting slammed by the list may miss.

 

[HemeOncHopeful19]

Reimbursement also not helping things. Itd be great if I could spend 30 minutes on every PET like in training but that’s nowhere near realistic with staffing and trying to maintain reasonable compensation.

I find this statement interesting. What would you consider “reasonable compensation?”

In my experience Rads are some of the higher paid docs (typically in the top quartile of specialties)?

 

[hopefulraddaddypls]

Thanks everyone - it seems like there are other people noting similar issues and it seems due to workload.

I had a patient last week with advanced head neck cancer go to ED with CN palsy and facial numbness. MRI read as negative. There is a mass in the cavernous sinus. He went home. Now, can’t open eye and pupil blown. The week prior he had a CT scan and you can see it a little there, as well. All the symptoms written in the order. Had to send him back and he was admitted.

This week, hx of lung cancer. And brain mri done for post tx surveillance. 5 mets. None measured and not counted. I get when it’s innumerable. But, it’s 5. Maybe that’s just being picky. But a couple measurements or at least of index would be nice.

When you call and talk to people and discuss cases, clearly they are knowledgeable and very helpful clinically. They take their time to talk you through findings. And you get the sense that if they just had the time, the work would also be more enjoyable, as well.

I don’t really think of this as fixable with modern medicine. The other thing is all my work was subject to evaluation by other physicians - there would be plenty of flaws to find. That’s the other part - there’s a microscope on you guys.

Yeah waste time measuring mets lmao this is insane

 

[WildRivers]

Yeah waste time measuring mets lmao this is insane

Is that how people feel about brain mets?

I’m old school. I like to compare by size and tell patients this. Maybe it’s a thing of the past.

 

[Radguy12]

Is that how people feel about brain mets?

I’m old school. I like to compare by size and tell patients this. Maybe it’s a thing of the past.

Your not a real person

 

[vm26]

I find this statement interesting. What would you consider “reasonable compensation?”

In my experience Rads are some of the higher paid docs (typically in the top quartile of specialties)?

Adjusted for inflation, CMS reimbursement for all physicians is down around 33% from 2001. For radiology and other subspecialties, it's probably higher (Due to budget neutrality, any reimbursement increase-eg. to primary care must be off-set by cuts to other subspecialties).

Last year CMS got creative and started with a new hit to radiology and other fields with an additional "efficiency" cut that diminishes our wRVU by 0.3% which is set to take place every 3 years. I know sounds insignificant but follows the theme of death by a thousand cuts.

As a result, physicians like radiologists have adapted by doing more, which means less time/bandwidth per case.

Yes radiologists get paid well but there's a reason why burn-out is common and older rads are retiring sooner than later.

On a positive note, there's a proposed bill floating around in congress that would limit CMS reimbursement cuts to only 2.5%/year (not adjusted for inflation)!

Spoiler alert, hospitals generally receive annual net increases from CMS (one of the reasons why private practice is essentially dead and physicians are typically employees with little say how they practice).

 

[Clean7795]

Hey Dx Rads friends -

I'm a radonc and I rely on radiologists to do my job. It is integral. I need your reports, your comments, helping me with tough cases.

I have noticed something last 5-7 years. The reads come back fast, but I don't see much critical thinking as I used to. It is narrative describing things, without the medical part - differential diagnosis, making a diagnosis (with room for hedging). I'm seeing 5cm tumors in open lung not commented upon. Have to ask after the fact to do comparison to something from the same PACS system that is obviously there. Something feels different to me - as the consumer of your reports. I feel like I have to re-review things and call often for corrections. Good reports used to stage patients with AJCC / TNM. I do a lot of SRS and after treatment after is "possible recurrence" - without discussion of ratio of edema to tumor or T1:T2 mismatch or anything to point us in the direction of RN or recurrence, etc. MRI prostates not highlighting the dominant nodules. I even write on the order the specific question I want answered and that doesn't happen. Of note, I've been in several locations during this time span (AZ, WA, MI - rural and Detroit suburbs). I can't even say one area is worse or better. I find specific ones who's reads I like, but often times because of the way the practice is set up, I can't say "please have so and so read my scans". If I had the time, I'd have a few major things every week to call them about to addend. I'm not kidding, a lung patient with 5cm tumor. I called, the guy was so embarrassed, I felt bad, I just said it happens, but I need an addendum. I was about to treat a patient with SRS, but the MRI looked bad. The report mentioned one met. I'm seeing lepto. NSG reviews with me - "don't SRS this, they have lepto". Called rads, same thing, apologies. There were 7 or so additional small mets we found, as well.

At times I get pretty upset, but I know how hard everyone is working in all of medicine, particularly dx rads.

Am I being too picky? Am I just having strings of bad luck?

Please don't think this as an attack. It's just becoming such an issue and I don't have the faith I used to any more. I know who goes into this field - it's typically the brightest and best. It just feels different, particularly the last few years.

This is an interesting post. To answer your question, it boils down to the fact that all external forces on radiology prefer high TAT rather than quality.

1. Hospital admin: Doesn't care about report quality. The only metrics that matters is TAT and how much we're willing to be paid per RVU. Sometimes the hospital admin don't even care about TAT and only care about $ so be glad you're still even getting timely reports.

2. CMS/government: Doesn't care about report quality. Unlike most other specialties I can't add-on codes for a CT abdo pelv w/con if I spend additional time doing it because it was extremely complex. There are no time-based or complexity code add-ons for the most part.

It's actually the exact opposite, where radiology codes tend to get bundled or cut over time for no reason (same labour, less pay). This tells me that the government/insurance/RUC committee feels image interpretation isn't that valuable to be reimbursed at that level. Okay, then there shouldn't be a surprise if lower quality service is provided.

3. Other physicians: Theoretically the people who should be holding radiologists accountable and grounded are clinicians reading the reports (like how clinicians are accountable to the patient facing them). That's kind of true, but the majority of clinicians mostly care about TAT. Those like yourself are the exception. Mostly physicians as a whole just want a fast report so they can get the patient out the door and move onto the next patient. No clinician is going to take or leave a certain job because the radiology department is awful/great.

We actually say this play out in the 2000s and early 201Xs where private groups who long had good relationships with referring docs, did stuff like TNM staging for docs like you, were displaced by large corporate groups who would do the case for cheaper and similar TAT, even if the reporting quality was awful. No non-radiology physician in the country went to their respective hospital to say "if X rad group is gone, I'm leaving!". Other physicians are okay swallowing slop if it means hospital admin saves a few dollars.

*Regarding your example obviously the rad should've caught the 5 cm tumor, that's just baseline unacceptable... but TNM, multiple comparisons, etc. that's a result of the above.

 

[jambro]

Adjusted for inflation, CMS reimbursement for all physicians is down around 33% from 2001. For radiology and other subspecialties, it's probably higher (Due to budget neutrality, any reimbursement increase-eg. to primary care must be off-set by cuts to other subspecialties).

Last year CMS got creative and started with a new hit to radiology and other fields with an additional "efficiency" cut that diminishes our wRVU by 0.3% which is set to take place every 3 years. I know sounds insignificant but follows the theme of death by a thousand cuts.

As a result, physicians like radiologists have adapted by doing more, which means less time/bandwidth per case.

Yes radiologists get paid well but there's a reason why burn-out is common and older rads are retiring sooner than later.

On a positive note, there's a proposed bill floating around in congress that would limit CMS reimbursement cuts to only 2.5%/year (not adjusted for inflation)!

Spoiler alert, hospitals generally receive annual net increases from CMS (one of the reasons why private practice is essentially dead and physicians are typically employees with little say how they practice).

Not 0.3%, 2.5%! So in 10 years a 22% nominal cut to rad work, ignoring inflation. Insanity

 

[HemeOncHopeful19]

This is an interesting post. To answer your question, it boils down to the fact that all external forces on radiology prefer high TAT rather than quality.

1. Hospital admin: Doesn't care about report quality. The only metrics that matters is TAT and how much we're willing to be paid per RVU. Sometimes the hospital admin don't even care about TAT and only care about $ so be glad you're still even getting timely reports.

2. CMS/government: Doesn't care about report quality. Unlike most other specialties I can't add-on codes for a CT abdo pelv w/con if I spend additional time doing it because it was extremely complex. There are no time-based or complexity code add-ons for the most part.

It's actually the exact opposite, where radiology codes tend to get bundled or cut over time for no reason (same labour, less pay). This tells me that the government/insurance/RUC committee feels image interpretation isn't that valuable to be reimbursed at that level. Okay, then there shouldn't be a surprise if lower quality service is provided.

3. Other physicians: Theoretically the people who should be holding radiologists accountable and grounded are clinicians reading the reports (like how clinicians are accountable to the patient facing them). That's kind of true, but the majority of clinicians mostly care about TAT. Those like yourself are the exception. Mostly physicians as a whole just want a fast report so they can get the patient out the door and move onto the next patient. No clinician is going to take or leave a certain job because the radiology department is awful/great.

We actually say this play out in the 2000s and early 201Xs where private groups who long had good relationships with referring docs, did stuff like TNM staging for docs like you, were displaced by large corporate groups who would do the case for cheaper and similar TAT, even if the reporting quality was awful. No non-radiology physician in the country went to their respective hospital to say "if X rad group is gone, I'm leaving!". Other physicians are okay swallowing slop if it means hospital admin saves a few dollars.

*Regarding your example obviously the rad should've caught the 5 cm tumor, that's just baseline unacceptable... but TNM, multiple comparisons, etc. that's a result of the above.

On the contrary I routinely steer patients to the local group in our area that does a good job of/ TNM staging etc.

I have a go-to spiel about how this group does a better job for cancer patients (they “get more practice because I work with them a lot”) and is worth the 45-60m drive from our rural satellite region to get a scan where they hold the contract for reads. Now, I am guessing Onc scans may not be super desirable to stack up due to complexity but quality reads do drive some business for that group IMO

If that group ever loses that contract I will definitely not be steering scans to that particular hospital

 

[dozitgetchahi]

Rheumatologist here.

To be blunt: most radiology reads of my joint x-rays are garbage. Erosions in RA and PsA patients are regularly missed, dictations are made with comments that make no sense (“no sign of rheumatoid arthritis related damage” in a lumbar x-ray where no such “damage” could occur).

I view all the x-rays myself because I cannot trust the local radiology reads unless they’re getting sent out to an MSK trained radiologist.

 

[Melkor]

I view all the x-rays myself because I cannot trust the local radiology reads unless they’re getting sent out to an MSK trained radiologist.

Not even joking. I bet the rads would love you if you told them the part where you are reviewing all the xrays. Maybe skip the reason though.

 

[LegendaryBibimbap]

The honest truth is we are also pretty poorly trained. We jump around from subspecialty to subspecialty for four years getting good at nothing, then pick one fellowship. Unless you care to continue to learning after training, there is no consequence to slapping garbage reads on xrays and moving on. In fact, slowing down to look things up costs money

 

[hopefulraddaddypls]

On the contrary I routinely steer patients to the local group in our area that does a good job of/ TNM staging etc.

I have a go-to spiel about how this group does a better job for cancer patients (they “get more practice because I work with them a lot”) and is worth the 45-60m drive from our rural satellite region to get a scan where they hold the contract for reads. Now, I am guessing Onc scans may not be super desirable to stack up due to complexity but quality reads do drive some business for that group IMO

If that group ever loses that contract I will definitely not be steering scans to that particular hospital

Lets see, read a bombshell CT AP on a cancer patient, or a pain scan neuroaxis on a 22 year old who got in a fender bender, really tough choice on what radiologists would rather read

 

[hopefulraddaddypls]

Rheumatologist here.

To be blunt: most radiology reads of my joint x-rays are garbage. Erosions in RA and PsA patients are regularly missed, dictations are made with comments that make no sense (“no sign of rheumatoid arthritis related damage” in a lumbar x-ray where no such “damage” could occur).

I view all the x-rays myself because I cannot trust the local radiology reads unless they’re getting sent out to an MSK trained radiologist.

Lumbar xrays are a waste of everyone's time, and that hand xray pays 10-15 dollars

 

[vm26]

Rheumatologist here.

To be blunt: most radiology reads of my joint x-rays are garbage. Erosions in RA and PsA patients are regularly missed, dictations are made with comments that make no sense (“no sign of rheumatoid arthritis related damage” in a lumbar x-ray where no such “damage” could occur).

I view all the x-rays myself because I cannot trust the local radiology reads unless they’re getting sent out to an MSK trained radiologist.

As someone who has completed 2 fellowships, I disagree that a MSK rad is needed. You just need a rad that has interest/experience in reading these types of exams-overall complexity is pretty low. Reimbursement however is punitive unless one is employed in an academic center.

 

[vm26]

The honest truth is we are also pretty poorly trained. We jump around from subspecialty to subspecialty for four years getting good at nothing, then pick one fellowship. Unless you care to continue to learning after training, there is no consequence to slapping garbage reads on xrays and moving on. In fact, slowing down to look things up costs money

Overall agree with your sentiments, though I do not think this is due to poor training. More to due with the increasing complexity in medicine and reliance on imaging.

How many breast surgeons due you know that can do basic general surgery work? What about basic ortho work? I know none, yet as rads we are asked to do all the above with similar expectations from clinicians in the backdrop of being more "efficient".

 

[maxxor]

As someone who has completed 2 fellowships, I disagree that a MSK rad is needed. You just need a rad that has interest/experience in reading these types of exams-overall complexity is pretty low. Reimbursement however is punitive unless one is employed in an academic center.

To be blunt: you need to read arthritis in black and white cover to cover and you can read these competently. Most people never do.

 

[colbgw02]

I'm MSK-trained who mostly reads bone, joint, and spine MRs.

The greatest per click value that I add are on radiographs. They're hard, and if you think you're interpreting them well then you're probably wrong. I'm mostly speaking to non-radiologists here.

I also get paid nearly 7 times as much to read an MR than I do a hand series. I cannot read 7 hand series in the time I can read a hand MR. You do the economics.

Want to know how many MRs I read this week for "preoperative planning" with stupidly obvious stage IV OA on radiographs? My kid will go through college from head CTs ordered by triage nurses.

I'll start worrying about spending more time on radiographs when the system and the ordering providers place the appropriate value on them. Instead, we overutilize advanced imaging, overwhelm the system, and then complain when quality slips.

 

[WildRivers]

That makes sense to me

Is there a world where we order something inappropriate and you guys just say “that’s not necessary, I wouldn’t advise you ordering that study”?

I’m not diagnostic, I’m ordering for staging and follow up per guidelines, if I ordered a PET on something that wasn’t indicated, it would not make me feel bad if dx rad said “you know, that’s not gonna help you in this scenario”

I say this because most of you are saying we order inappropriately and too many scans overall. I’m always open to guidance.

It happens with us, someone will curb side me if someone may need RT and if it’s 100% unnecessary I say they don’t have to send. I don’t expect them to know what is and isn’t indicated.

I think they same way for you as the ordering docs - there’s just so much work to be done and the ordering quality / quantity is suboptimal bc of this.

 

[Radguy12]

That makes sense to me

Is there a world where we order something inappropriate and you guys just say “that’s not necessary, I wouldn’t advise you ordering that study”?

I’m not diagnostic, I’m ordering for staging and follow up per guidelines, if I ordered a PET on something that wasn’t indicated, it would not make me feel bad if dx rad said “you know, that’s not gonna help you in this scenario”

I say this because most of you are saying we order inappropriately and too many scans overall. I’m always open to guidance.

It happens with us, someone will curb side me if someone may need RT and if it’s 100% unnecessary I say they don’t have to send. I don’t expect them to know what is and isn’t indicated.

I think they same way for you as the ordering docs - there’s just so much work to be done and the ordering quality / quantity is suboptimal bc of this.

Many clinicians will still want the study done regardless of what you tell them. You can tell someone hey I'm not gonna treat this for XYZ reason and the buck stops with you. Not how it works with rads sadly. And we see significantly more cases a than you or any other clinicians. At some point it's not feasible given how many stupid orders come from the ec, inpatient and often outpatient clinicians. And for admin, the more studies the merrier even if they are not indicated. You all don't value our clinical judgement

 

[maxxor]

I would reframe the “overwhelming volume”.

If you take out the ER and misc midlevel ordering out of the picture, I’m not sure it’s all “non indicated studies”.

The bottom line in the outpatient world is that radiology is more important than ever to modern patient care

And

We have a system hell bent on shifting reimbursement to the technical / hospital side vs the physician side.

The volume and economics have reached a breaking point where we can’t keep income where people want it without reading what used to be considered insane volume and complexity is increasing even more.

As of right now quality is slipping to meet the TAT and people’s target incomes but a few more years of physician side cuts and I could see rad groups abandoning bad contracts en masse. Or just straight up collapsing.

Radiology has crossed into the anesthesia realm where the physician reimbursement is completely divorced form the system value. In anesthesia hospitals are willing to pay to keep the ORs running out of the technical/facility fees. They haven’t yet learned they need to pay to keep the scanners running in the same way.

 

[vm26]

Many clinicians will still want the study done regardless of what you tell them. You can tell someone hey I'm not gonna treat this for XYZ reason and the buck stops with you. Not how it works with rads sadly. And we see significantly more cases a than you or any other clinicians. At some point it's not feasible given how many stupid orders come from the ec, inpatient and often outpatient clinicians. And for admin, the more studies the merrier even if they are not indicated. You all don't value our clinical judgement

A lot of studies (OP studies without preauthorization, observation ER/in-pt exams) do get reimbursed for the pro-fee. Same studies may get reimbursed from the tech fee (HC systems with much stronger lobby). Patients prob get hit with the bill at times but good luck collecting.

 

[vm26]

Radiology has crossed into the anesthesia realm where the physician reimbursement is completely divorced form the system value. In anesthesia hospitals are willing to pay to keep the ORs running out of the technical/facility fees. They haven’t yet learned they need to pay to keep the scanners running in the same way.

HC systems are slowly catching on. We can sizable subsidies from the HC system to bump up our $/wRVU.

 

[colbgw02]

HC systems are slowly catching on. We can sizable subsidies from the HC system to bump up our $/wRVU.

I'm seeing this, too, and not just from the hospital admin suits, but also from VC. Even the MBAs are starting to realize that the machine doesn't work without the cogs.

 

[Neuronix]

I'm seeing this, too, and not just from the hospital admin suits, but also from VC. Even the MBAs are starting to realize that the machine doesn't work without the cogs.

It's all supply and demand.

As soon as there's an oversupply of radiologists they will be happy to pay less for the radiologist cogs and replace any squeaky ones.

 

[Maybedoc1]

It's all supply and demand.

As soon as there's an oversupply of radiologists they will be happy to pay less for the radiologist cogs and replace any squeaky ones.

I’m just a lowly R1 but I’m not sure if there will be an oversupply of radiologists any time soon. Imaging volumes are skyrocketing, but DR spots have only increased 10% over the last 15 years. I believe the average radiologist is in their 50s (or close to it) from what I’ve read also. There’s zero midlevel encroachment in the field. There’s always a risk of AI but I’m seeing the fancy AI that my hospital uses flag choroid plexus calcifications as an ICH so I think it might be awhile before it’s replacing radiologists.

 

[hopefulraddaddypls]

I’m just a lowly R1 but I’m not sure if there will be an oversupply of radiologists any time soon. Imaging volumes are skyrocketing, but DR spots have only increased 10% over the last 15 years. I believe the average radiologist is in their 50s (or close to it) from what I’ve read also. There’s zero midlevel encroachment in the field. There’s always a risk of AI but I’m seeing the fancy AI that my hospital uses flag choroid plexus calcifications as an ICH so I think it might be awhile before it’s replacing radiologists.

I think we need to hold the line on spots. But academic people used to easy cheap labor are not happy about the current shortage, and theyre bowing down to these clinicians who are upset with TOT>2hrs, which wasnt the norm 10 years ago