Headset vs. Handheld vs. Fixed Microphones

There are three main form factors for microphones in the context of a radiology setup.

You can hold a dictaphone, as radiologists have done since time immemorial. You can wear a microphone like a headset. Or you can have a microphone that is not in any way on your person.

There are pros and cons to each solution.

The pro of the old standby handheld microphone is that it contains dictation controls, allowing you to manipulate dictation software with your nondominant hand. As I’ve discussed elsewhere, this is the wrong solution for efficiency and for ergonomics. The limitations of the built-in dictaphone tools are too numerous for it to be the right answer—even though it is the default solution.

I believe every radiologist should drop the dictaphone and use something else with their off hand. An off-hand device like the one I use can more effectively manipulate both dictation software and PACS and is less likely to cause repetitive strain or ulnar neuropathy.

An off-body solution has the benefit of freeing up your hands while also remaining plug-and-play. The microphone stays where you put it and just works when you log in. No effort needed and—with the right microphone—can be very effective.

There are infinite options. The Rode VideoMic NTG, a shotgun microphone I attach to my monitor and point at my face, has been my home dictation solution for several years now. It is efficient, effective, and works every time. I find it effortless and surprisingly resilient to slouching. The main downside to that solution is that you are still somewhat more susceptible to ambient room noise and posture (note: some users have reported intermittent problems with this microphone of varying degrees of annoyance, so another USB shotgun may or may not be better).

For some radiologists, the preferred solution is a headset microphone, which has the added benefit of moving with you so that it always accounts for position regardless of where you are relative to your desk and is less susceptible to ambient noise.

While you could also use a lav mic clipped to your clothing, but a headset also allows you to use headphones with your computer, meaning you can handle meeting requests like Zoom/Teams and listen to music without needing a second device.

For many years, headsets for dictation functionally required a wired USB connection, as Bluetooth and wireless dongles were simply too unstable, slow, and choppy for dictation accuracy. But if you don’t mind a little lag, that is no longer the case.

Headsets, like headphones more generally are very much a personal preference thing. I included several fan favorites in the equipment post, but my preferred headset solution is these Shokz bone-conduction headphones, specifically the Shokz OpenComm2 UC for several reasons. This style has become very popular with runners because you can’t lose them as easily as earbuds and you can still hear the ambient world around you for safety (I still like the AirPods Pro 2 with transparency mode).

One perk is that the Shokz are incredibly light and comfortable for long periods of time. Over-ear headphones can feel hot and are often heavier, resulting in fatigue over a long shift. There was a time as an early attending that I often used a cheap wired Plantronics headset, but I actually usually wore them around my neck with the mic arm angled toward my mouth for comfort. I think the over-the-ear behind-the-head form factor is overall more comfortable for long-term use. The Shokz are light enough that it’s basically possible to forget you’re wearing them, which I would say is ideal.

The bone-conduction pads on your tragus are non-intrusive and do not block ambient noise. This can be both a pro and a con—in the sense that if you are working in a loud place (such as next to the magnet or at home while doing laundry), you are not going to block out the room noise.

But it also helps if you want to deploy a headset while working with other human beings and wanting to be able to hear the noise around you. It means people can talk to you, and you can hear them—and that you can answer the phone and still use a receiver without needing to remove your headset.

So, for some work situations, this is ideal.

The battery lasts for a long time (reported 16 hours of dictation, 8 hours if playing music), though one downside is that the charging cable is proprietary—so you’ll have to keep the cord handy for charging (it fits in the included carrying case). A 5-minute quick charge provides 2 hours of talk time. I haven’t had battery issues yet, but since the tiny battery inside is like literally every other lithium battery in the world, I expect this to degrade eventually.

You can connect via Bluetooth, but it also plugs in easily with a USB-C (or USB-A) dongle that is safely secured in the carrying case. My understanding is that the quality with the dongle is slightly better.

If you are looking for a portable solution that reliably works, allows you to use them as functional headphones and attend Zoom/Teams calls—but also doesn’t isolate you from the rest of the world—the Shokz is, I think, a good solution for radiology.

A couple of very important limitations:

1. There is a slight lag when activating dictation, where you might notice degraded accuracy at the beginning of a phrase. You really need to use toggle on/off controls and not the deadman switch, and your accuracy will be way better if you just keep dictation turned on while reporting. Once dictation kicks on, transcription speed is fast and accurate. I think you will need to break the habit or toggling dictation on/off repeatedly for every discrete phrase or you will hate them.
2. Audio quality is lower when you’re actively using the microphone dictating, so if you are toggling back and forth all the time it’ll keep switching between higher and lower fidelity modes. It’s annoying. Bone conduction headphones aren’t audiophile quality anyway, but you’ve been warned. Because your ears are uncovered, if you don’t mind looking like a psychopath, you can keep AirPods in your ears while wearing the headset, which means you can have incredibly flexible audio input/output between your computer and cellphone. I wouldn’t listen to music via them while working.

I’ve been using the Shokz as an alternative to my cheap desk-clamp-to-hold-the-dictaphone method when at imaging centers, which allows for some more position flexibility (and the chance to channel your inner telemarketer.)

If you don’t need the headphones part of the headset but want something portable, you might instead try a lavalier format like the wireless Hollyland M2S.

It’s easy to measure radiologist productivity in terms of RVUs per hour.

What’s harder to assess is how efficiently a radiologist reaches that production number—both cognitively and psychologically.

I’ve written a lot about the biomechanical side of reducing friction in the radiology workflow: better input devices like programmable mice, off-hand keypads, and simple AutoHotkey scripts. But there’s another important piece—minimizing distractions and maintaining momentum from case to case.

On the macro shift level, you can have so-called bunker shifts free of technologist and clinician phone calls and other external distractions. Literature has shown, big surprise, that on the whole, people read more if you don’t interrupt them. But there are two issues with that:

1. Talking to people is part of the job, at least some of the time.
2. You can still distract yourself.

Auto Advance

One simple but powerful tool is AutoNext or equivalent automatic case-loading function in your worklist manager. When you sign a case, the next one opens automatically.

This reduces the liminal space between cases—those tiny gaps where your monkey mind looks for distraction, dopamine, or the occasional excuse to manipulate a shared worklist to avoid difficult or low-RVU studies.

(We can however acknowledge that automatic case selection/loading can increase the feeling of being on an endless hamster wheel, but overall I still believe it’s ultimately effective in removing some useless clicks and unnecessary decisions.)

Enough with the Email

Another low-effort win: don’t keep your email open in a browser tab. Just closing the tab dramatically reduces the urge to check email every five seconds between cases, especially when you can see the unread message counter climbing.

We are always looking for an excuse to disengage when a task gets hard. Your phone may be in your pocket, and you may need to be reachable, but it’s still better to batch-check email sporadically than to leave it constantly accessible.

Phone Just Out of Arm’s Reach

I need to be able to answer the phone. Anyone who needs me generally is going to call my cell or text, and I also forward the hospital phones to my cell phone when covering from home. This is one reason why I often keep an AirPod or two in my ears most of the time when I’m working alone: I can hear and answer the demand without needing to have my phone on my person. Just a little friction can go a long way.

Creating vs Editing

One feature I’ve come to really appreciate in my practice is access to a team of human editors (the imaging center pays)—someone who helps input clinical histories, contrast details, catch template mismatches, and fix obvious transcription errors. They’re not perfect, and they certainly don’t always make big changes, but the value isn’t just in the edits themselves.

What the editor allows me to do (only when I’m on an outpatient list) is separate the diagnostic report creation task from the editing task. I can read multiple cases in a row, focusing on interpretation and moving efficiently down the list—then switch into editor mode to proofread and finalize my reports. I catch more of my own mistakes with those few minutes of temporal distance.

This separation is key. Constantly switching back and forth between different cognitive modes creates attention residue (not to mention editing fresh words is always a challenge as your mind often sees what you meant to say and not what’s actually there).

While avoiding distractions like email, phones, and messages is intuitive but challenging, task batching is an overlooked opportunity (obviously only when working on non-time-sensitive cases). Diagnostic, then editorial. Not both at once. It’s a subtle shift, but I’ve found that when practical it makes a real difference in my focus, efficiency, and effectiveness.

I’ve been fielding job questions via email over the past months and after my talks at RSNA, ACR, and ASNR, so it seemed like the easy solution was to collect some responses here for dissemination (instead of trying to turn them into a bunch of separate posts).

As always, no one has to agree with me.

Private Practice

Is private practice still viable?

and

If private practice is so great, then why are so many groups struggling and failing?

See my answer here.

Teleradiology & Locums

So many people seem to want to do teleradiology, is the stigma/taboo gone?

The taboo is absolutely gone in the sense that you won’t be shunned, but I think many groups still find tele to be a necessary evil brought on by market demands. Off-hours swing/overnight work aside—where I think there is absolutely a growing realization that there is a very important and meaningful unique value in providing that service just like there is for driving around and doing fluoro—I think people generally find it frustrating and would be happier if they didn’t have to resort to hiring for it.

To be clear, everyone loves a hybrid work schedule, and almost everyone wants to work from home sometimes. But hiring 100% remote rads to absorb remote work often means a greater fraction of on-site work for local rads and an altogether different kind of easily comparable job.

This often results in functional dual-class structures in order to create fairness between on-site and remote rads etc. That might be no remote partners. That might be higher RVU requirements. That might be less pay. It varies.

I suspect that, over the long term, cultural dilution may be a real problem, and I’m not sure it isn’t intrinsically destabilizing for the field. I suspect we will see multiple larger tele practices opening up and grabbing business. Things are so hot that they can get great rates from desperate hospitals. I don’t know how sustainable any of this is.

Is the teleradiology trend temporary?

Overall, I think the teleradiology trend is real and not going anywhere. And at least for those willing to do off-hours work, like evening swing shifts and overnight, the demand for those services will probably never go away so long as humans are involved in interpreting diagnostic imaging. I think for the foreseeable future, there is really no reason why anybody needs to be on-site for most of those jobs.

For better or worse, there is a growing contingent of people, including fresh graduates, who want to have that same lifestyle experience during the daytime. Part of that cohort are those who are unhappy in their current positions—fairly or unfairly—and looking for greener pastures but don’t want to uproot their families and move. I do think some of that trend may go away if we do see significant efficiency gains with the coming radiology products over the next few years. Some of the AI stuff is hype or won’t change productivity, but some of it is absolutely real. You don’t need to replace a radiologist to completely change supply and demand in the workforce.

If an organization becomes fully staffed or—hard to imagine—overstaffed, the first person to go is the remote, employed or (especially) contractor, daytime-only-no-weekend teleradiologist.

I think one question becomes, if that happens, how much of a chilling factor does that lead to for the tele market and does it create an opportunity to create meaningful on-the-ground jobs again in radiology? Right now, nobody wants to do the work of practice building, procedures, and other personal touches. I think the COVID era broke a lot of residents’ brains and has made many completely discount how important meaning and connection are to long-term satisfaction. I think those residents have taken the physical component of the job for granted and don’t realize how isolated they will be working from home all the time.

Yes, work-life balance etc is better as a remote worker. The lack of a commute is a huge deal. I absolutely do like working from home for a fraction of my job. And I absolutely think that in 2025, even many happy local rads are essentially demanding a hybrid schedule. But there is a difference between regularly or frequently working from home and always working at home.

I think at least some young radiologists are chasing a good job but perhaps not building a meaningful career. I’m not sure that is a great long-term plan for life satisfaction for a 30+ year career for everyone making that choice, even if it does unquestionably make your life easier day-to-day. At the same time, we shouldn’t paint with too broad a brush either; there are obviously individuals who are much, much happier working 100% remote for a wide variety of personal reasons, and certainly not all 100% remote jobs are the same. If nothing else, simplified school logistics alone are huge.

Anyway: different strokes, and all that.

It seems like locums folks are making great money, is that what I should be doing?

Many hospitals are fine paying high rates temporarily out of need but are terrified of agreeing to a healthy long-term. Part of this is organizational dysfunction in the sense that ultimately the managers’ skin in the game is limited: overpaying out of necessity isn’t their fault, but signing a costly contract makes them look bad (and they worry about ripples across the org). This is compounded by, I think, a willful ignorance of the state of the market (which more are coming around to now). Needless to say, I think this particular strain of management is shortsighted.

No doubt, you can make good money as a mercenary right now and for the foreseeable short-term future. The question is, when things shift, can you find yourself good employment or are you left out to dry with slimmer, less-desirable pickings? Nailing the landing could be hard or it could be a total non-issue. But the nature of locums is that you can usually make more money—especially if you’re geographically or temporally flexible—because you’re trading safety and stability in order to fill those urgent, well-paying coverage gaps. Nothing wrong with that as long as you acknowledge the tradeoff.

Training & Mobility

Do I Need to Do a Fellowship?

To get a job? Absolutely not. There are jobs right now for fresh trainees without a fellowship.

To get a specific job? In many cases, yes.

There are plenty of places—both groups and hospitals—that still want fellowship training for radiologists, whether that’s because the paper has actual value, because the marketing of said paper has value, or because they want specific skills that are hard to get on the job without some pain or investment and are easier to build on with that additional foundation.

It’s not unreasonable for residents to ask themselves the fellowship question—especially since, while many radiologists don’t necessarily do a lot of deliberate learning on the job outside of gradual improvement with experience, we do know that we can learn new things if we want to, even outside of the confines of a residency training program.

If you want to forgo a fellowship and there’s a place you want to live—especially if you’re willing to be in smaller or more rural areas—it makes sense to ask those groups.

It makes sense to go look at job listings (on Independent Radiology, for example) and see if there are options in the right spot.

If it’s not clear from the internet, then start the real job search early, put feelers out, and find out if people are willing to give you a job that you actually want without additional training.

The follow-up question is always: “But what happens if I don’t like that first job?”

And to that, I have no idea.

There are certain situations where fellowship is permanently important. For example, there are some hospitals and places that truly do want to have CAQ-holding neuroradiologists on staff, and that is something that is challenging to achieve without playing the game.

But in many other situations, multiple years of experience should matter more than how you spent a single year a decade in the past.

So the reality is: if you stay in your first job for five years and then move to another one, is anyone going to care that you didn’t do a body fellowship?

I would think not—but I couldn’t say for sure. Probably depends on how subspecialized you’ve been in practice and what your skillset actually is. Fellowship is certainly a terrible proxy for skill, but it is still widely used.

I think if you do take a job and you hate it and you want to quit within a year—that might be more awkward. But as long as the radiology shortage persists, I think you’ll have some flexibility on that front.

What’s the downside if I hate my job and leave it?

Well, for one, it’s sad—and it means that you probably didn’t enjoy yourself while you were working there.

Logistically, it means you’ll probably have to deal with a non-compete, which could mean either working in a different geographical area—possibly needing to move—or entering the remote teleradiology workforce.

Now, you may not mind working 100% remotely, but for those who were hoping to have support, connection, and community (particularly in their early career), that may be less fun.

If you’re interested in becoming a partner in a private practice, it means you’re going to have to restart that path when you get your next job—which again may not even be possible if you’re working as a teleradiologist. Given the relatively short workups these days, this is less of an issue today than even just a few years ago.

There may be some mostly minor benefits issues: delayed 401(k) access, potentially lost 401(k) matching, giving back signing bonuses, paying for tail insurance, and other such things.

In reality, all of the financial considerations can be handled, mitigated, and dealt with—and none are the end of the world.

If you are a remote employee leaving your current gig to be a remote employee somewhere else, the downside obviously is mostly just that breed of transient hassle, maybe learning a new system, etc. There’s no reason for us to pretend that in our increasingly mobile workforce that swapping tele gigs necessarily carries a huge cost. The musical chairs that teleradiology enables is one of the reasons the market is so crazy right now.

Mammo

What on earth is going on in breast imaging??

High demand and low supply, coupled with typically high reimbursement and productivity of breast imaging.

An increasing share of trainees have been drawn to breast by the market. Of course, many are intrinsically passionate or want a patient-facing job without the IR lifestyle and stress, but we should also just acknowledge that some are chasing the perceived chill of well-paying jobs with no evenings, weekends, or call. For this latter group, I am somewhat more concerned, if only because picking anything based on the current state of idiosyncratic and unpredictable market forces seems like a pretty poor decision metric.

(But, as long as they won’t be disappointed when things change, obviously it can be a very fulfilling career even if it wasn’t some deep-seated passion. I think passion is highly overrated. Breast imaging isn’t going anywhere, and the personalized patient counseling component and procedures remain critical healthcare tasks that are obviously deeply meaningful to both doctors and patients and not as prone to outsourcing or AI disruption.)

We currently live in a world where “telemammo” is definitely a thing, of course in part to remote diagnostic coverage at far flung centers but also capitalizing on screener volume and specifically tomo to allow for things like really well-paying 4-day 100% remote breast jobs without call. Some of that is often remote diagnostics with actually talking to patients variable/optional and all procedures driven to either centralized on-site staffed locations or to specific days when coverage is present. (I haven’t done any breast imaging since training, but I will admit I honestly don’t get the idea of breast imaging with essentially zero direct patient contact.)

As a semi-outside observer of women’s imaging, I think the opportunity for disruption there is extremely high, and the odds of those jobs staying the way they are–often “higher” pay and “better” lifestyle than other rads–is perhaps the least likely status quo to remain completely unchanged. For one, we aren’t done seeing screening reimbursement cuts, especially for tomosynthesis, which I’m told is currently the biggest financial driver for enabling all these shenanigans.

To top it off, the corporate footprint in breast imaging is large (Solis, SimonMed, RP, etc) and the economic case for AI for these companies is huge. If you ask around about AI in radiology, it’s AI for breast screening that really gets these folks salivating. And that’s because AI-enabled improvements to productivity and efficiency for screening mammograms could be more easily economically profitable compared to essentially any other part of diagnostic radiology.

Give me an AI tool that provides a frequently signable report like an upper-level resident, and that will make me more efficient, yes, especially for certain things such as radiographs, but the reality is that me reading twice as many radiographs doesn’t yield massive RVU gains or windfall profits. Thanks to the BIRADs reporting structure, breast imaging is already the most standardized written report of anything in all of radiology. If AI-generated reports were ready to click and go for the majority of screeners with a well-calibrated callback rate—and there are no breast-specific legislative rules preventing their use as an autopilot, which of course there could be—then I think that would move the needle. I don’t do any breast imaging and only vaguely know the volumes in play with the current shortage, but I would suspect that it wouldn’t take a massive efficiency gain (20%?) to fundamentally change the supply and demand that has led to these lifestyle positions that have essentially derailed recruitment and retention throughout radiology, especially when it comes to young rads.

I am not exactly sure why no one is talking about this, but I’ll admit I was hesitant to include this part in the Q&A. Because to be clear, I’m not saying breast is “easy” or that breast imagers are going to be replaced first or any nonsense like that. Obviously nothing on the market right now is anything other than an improved CAD, so nothing is happening currently. I certainly don’t put stock in my predictive capabilities, but I do think this recent post-tomo status quo with breast over the past few years is the least sustainable part of the radiology workflow, if only because with the money at stake and the narrow task, the opportunity for disruption is too high (but yes, on an unknowably multiyear timescale). Either a change to reimbursement or productivity or both could easily substantially adjust the sweetheart offers of these employed and private-equity positions that are driving the market.

I don’t know when, and I don’t know if breast will actually be affected more than other subspecialties with AI, because it’s possible that radiology capabilities of the coming vision-language models will be satisfactorily broad across the whole field. I do know companies are looking at mammo as the exciting thing they’re willing to actually pay money for in AI. Anyone can see that the current tools are overhyped and brittle, but it’s also a mistake to assume that everything is and will remain vaporware, especially for narrow diagnostic tasks.

Of course, how things get deployed and what guardrails are put in place are total unknowns, and the timeline and scale of reimbursement changes are a constant battle.

But to answer the question: in addition to body/general radiology skills, breast is the most in-demand subspeciality. For now.

Clinicians can bill, at least to an extent, to account for complexity. When a patient walks into a clinic for an annual physical, an acute upper respiratory tract infection, or an endless litany of chronic complaints including uncontrolled hypertension, diabetes, and hypercholesterolemia, and an acute complaint, their documentation and the codes they use can differ between a brief med check and some more demanding undertaking.

Modality ≠ Complexity

In radiology, we don’t have complexity. We have modality. MRIs earn more than CTs, which earn more than ultrasounds, which earn more than radiographs. There is no distinction between a unindicated pre-operative screening CXR on a healthy adult and an ICU plain film. There is no distinction between a negative trauma pan-scan in an 18-year-old and a grossly abnormal pan-scan in a 98-year-old with ankylosing spondylitis, multiple fractures, and a few incidental cancers.

Leave aside adjusting actual reimbursement RVUs from payors and the government, which is beyond the scope of this essay and would require changes that are likely ultimately unhelpful in the sense that assigning RVUs for reimbursement is a zero-sum game: paying more for one thing will mean paying less for others. Yes, the reality is that some groups and some locations do have more complex cases than others, but capturing that in a fair way by a third party would be a substantial challenge and one with clear winners and losers. Reimbursement has never been fair: between the wide range of complexity and payor contracts, some doctors (or at least institutions) are simply paid more on a per-effort basis.

Internally, however, a group has limitless wiggle room to adjust internal accounting to reward effort and pursue fairness. Again, on the whole, in an ideal world, everyone receives a combination of easy and hard cases, and therefore everyone’s efforts will, on the whole, be comparable. In practice, this may not be the case in many contexts.

For example, a community division in a large university practice may not be reading the same kinds of cases as their counterparts working in the hospital. Some attendings work in rotations with junior residents, and some don’t. Different shifts and different silos across practices that involve different hospitals or different centers can vary widely, and even imaging centers in strip malls may draw different kinds of pathology by zip code and referral patterns. Even covering the ER may yield different sorts of cases with different issues, depending on the time of day. Deep night, high-speed MVCs at 3 am at your hospital may be different from the parade of elderly falls that come during the late morning. If all radiologists share in the differing kinds of work equally, no biggie, but especially in larger practices, that is not always the case.

Across modalities and divisions, it can be relatively straightforward to account for an internal work unit according to generalized desirability or typical time spent. A group might choose to bump the internal RVUs of radiographs and decrease them for some varieties of MRI. A group might decrease single-phase abdomen/pelvis CTs and increase chest CTs. A group might bump thyroid ultrasounds but decrease right upper quadrant ultrasounds. These sorts of customized “work units” based on average time-to-dictation are common.

But the problem of variable challenge within an exam type is thornier. Complexity varies, and preventing the peek-and-shriek cherry pick is a nontrivial task. A normal MRI of the brain for a 20-year-old with migraines is a different diagnostic challenge than a case of recurrent glioblastoma with radiation necrosis or progression.

Most of the metrics one could use to attempt this feat on a case-by-case basis are gameable and ultimately not tractable. If you use time spent to read the case, it’s very challenging to normalize across individuals with varying intrinsic speed, let alone the fact that someone can open an easy case and leave it open while dropping a deuce. I don’t think anyone wants to live in a world where Big Brother is tracking their mouse movements or other invasive surveillance. Radiologists have a hard enough time fighting the widget factory worker mentality enough as it is.

But even when everyone behaves nicely, having a system that accounts for tough cases would help with frustration, burnout, blah blah. No one likes to get bogged down in a complex case and feel behind. What constitutes a solid day’s work depends on how hard the work is.

Enter the eRVU

Here’s an example of how the scalability of AI could make an intractable problem potentially tractable: the use and application of LLMs on reports after the fact to create a complexity grid to help account for case difficulty. Such a model (or wrapper) could be trained to create a holistic score using a variety of factors like patient age, patient location, indication, diagnosis codes, ordering provider, prior exams and arduousness vs ease of comparison, number of positive or negative findings, and the ultimate diagnosis.

Now, obviously, such solutions—like all things—would be imperfect. It may even be a terrible idea.

For one, you’d have to determine how to weigh and differentiate between essential findings or extraneous details such that dumping word salad into a report does not increase the complexity score when it does not meaningfully add value. We all know that longer is not better. But I think if people are creative, viable experiments could be run to figure out what feels fair within a practice and how to drive desired behavior. It’s possible a big powerscribe dump with report data could yield a pretty robust solution that takes into account what “hard” and “easy” work looks like historically based on report content and the time it took to make it. Or maybe you need to wait for vision-language models that can actually look at pictures.

Again, a non-terrible version of such a product would be for internal workload and efficiency accounting, not for reimbursement. Think of it like the customized wRVU tables already in use but with an added layer that it would work across all exam types instead of just modality.

With an effortRVU, we could account for the relative complexity of certain kinds of cases within any modality. We could account for the relative ease of an unchanged follow-up exam for a single finding, and we could account for the very heavy lift that sometimes drives certain types of cases to be ignored on the list, like temporal bone CTs or postoperative CTs of extensive spinal fusions with hardware complications.

Providing good care for the most challenging cases should never be a punishment for good citizens.

(Yes I’m aware some institutions already use an “eRVU” for educational activities, meetings, tumor boards, etc. Accounting for non-renumerative time is also a defensible approach, but that’s not related to the challenges associated with variable case complexity itself.)

((It’s also worth noting that it’s also not hard to imagine a world where payors try to do things like this without your permission. Long term, how reimbursement changes for work in a post-AI world is anyone’s guess because all the current tools suck.))

Infighting & Fun

Any attempt to differ from the status quo, any variation of customization—whether simple wRVU tweaks or something more dramatic like this—is inevitably fraught. The more such a solution is based on messy human opinions, the more contentious the discussions would likely be. Everyone has an opinion about RVUs, and no one wants to see their efforts undervalued. Every tool is just a reusable manifestation of the opinions that go into it. For example, historically common complaints about the RVUs of interventionalists (often ignoring the critical clinical role our IR colleagues play and the physical presence it requires) are a cultural and financial problem, but probably not an AI one.

It’s worth noting that the desire to not “downgrade” work or deal with infighting is probably why many practices choose to change daily targets and bonus thresholds based on subspeciality, shift-type, etc instead of creating/adjusting work units. It’s the same idea tackled less dramatically from a greater distance.

Counting every activity (phone calls, conferences, etc) is also something that’s been deployed in some settings, but it’s easy to see how taken to extremes such efforts to reward behaviors can veer too far into counterproductive counting games and even tokenizing just being a decent person.

If there is a “right” answer, it may be specific to the company and the people in it, and adding complexity to the system has its own very real costs. Nonetheless, there is a strong argument to be made that some degree of practice effort to make sure that everyone’s work goes noticed and appreciated in a “fair” way is a step in the right direction for subspecialized practices.

Internal productivity metrics help prevent low effort output while smart worklists and other guardrails can ensure largely ethical behavior within the list. (But sure, theoretically, if you can solve case assignment, most everything else that matters should just even out in the long run.)

Ultimately, radiology is a field where, especially in large organizations, it can become easy to feel like an anonymous cog. Individualizing productivity accounting to truly recognize the hard, challenging work many radiologists do—and reward those who are willing to develop expertise and do a good job reading complicated cases—might help humanize the work.

(Or…maybe it would just be more stressful and counter-productive to get less credit for those easy palate-cleansers, I don’t actually know. I do know that this particular food-for-thought is bound to make some people very uncomfortable. You can tell me how far you think the gulf between possible and desirable is.)