Optimizing for $/RVU

How radiologists generate revenue is straightforward (you read cases), but how they are compensated varies based on the employment model, practice structure, payor contracts, stipends, etc etc etc.

Comparing opportunities is challenging. One way to attempt an apples-to-apples comparison is by summarizing a position into a single figure: $/RVU.

You take your total compensation, divide by RVUs, and voila. If you earned $300,000 and generated 10,000 RVUs, then you made about $30/RVU. Easy peasy (assuming your RVUs are accurate and you actually use the correct compensation number to account for benefits when applicable etc).

The math is straightforward, and it’s a helpful metric that I always include in my job talks.

But:

A lot of nuance hides behind that single number: casemix, case complexity, shift hours, evenings/weekends, procedures, benefits, IT and operational friction, vibes, etc. How many RVUs you generate is impacted by the kinds of work you’re doing per unit of time as well as how many hours and days you work overall. Despite the intention behind RVUs, not all RVUs are created equal.

For some contractor positions or those with strict productivity-compensation, $/RVU is logically the metric many people want to optimize for. Understandably so, and this is probably the fastest-growing segment of the workforce.

As always, Goodhart

But as Goodhart’s Law states: “When a measure becomes a target, it ceases to be a good measure.” I would argue that, at least for some radiologists and probably many graduating trainees, the question isn’t only—or perhaps shouldn’t be—just reduced down to a core metric of how much money did I make this hour? The deeper question is: am I doing this job in a way that makes me feel more human, good, honest, and interested?

If that question resonates with you, the problem with addressing it is that metrics are easy and comfortable. Optimizing for them feels right if we’re trying to be rational. Fluffy things may be important, but they feel easier to be wrong about. When we’re making decisions based on a regret minimization framework, I suspect many people feel they’ll experience less regret when optimizing for metrics that accurately reflect at least a portion of reality—rather than optimizing for metrics where they fear they may exercise misjudgment.

Choosing the best-paying job feels defensible and likely to reduce regret if it ends up sucking. Choosing a job for vibes or culture seems risky—because you’ll feel more likely to believe you made the wrong decision after the fact. Making the soft call doesn’t protect you from the pains of hindsight bias. Surely, the signs will have been there when you filter the past through your knowledge of the present.

The narrative fallacy is a fallacy for a reason: we simply aren’t that good at making predictions. Choosing where to work has inherent, unavoidable uncertainty—no matter how you make decisions.

Staying Comfortable

Then, once we’re working, we should also acknowledge the role of status quo bias, which—for this context—we can summarize as: we are comfortable with things as they are, even if we don’t like them, and even if we might like alternatives more. This is especially true when alternatives carry uncertainty, but it still applies when some improvements are essentially certain.

When we do entertain change, we often rely on an instigating factor or wake-up call to alert us to the possibility of choice. We are not good at counterfactual thinking. We are usually unable to view what our life would have looked like if we’d made different decisions, and we often fail to imagine what life could look like until something forces our hand to overcome this cognitive inertia: the resignation of our work sibling, the unfair treatment of a close friend, frustration with a bad mistake, an uncollegial interaction, or a rendezvous with a former colleague whose grass seems so much greener that your mind rattles trying to reconcile the different universes you seem to inhabit.

No job is perfect, and comparison is certainly the thief of joy. Ideally, we would like our jobs and not regret our choices. But we should also be comfortable with the reality of the sunk cost fallacy: time spent in the wrong career is time already spent. We don’t need to be shackled by previous choices or gambles that didn’t pay off.

It’s possible to make a “good” choice based on the available information and have it not work out. It’s possible to make a choice for the wrong reasons and still win. We should always strive to optimize our processes, but still acknowledge that our ultimate desire is the happy outcome of a fulfilling journey.

In the end, I guarantee someone out there is making more per RVU than you are. You can, at least in part, choose how that makes you feel.

$$$

The radiology gig economy is growing, and the desire for remote positions and continued consolidation is pushing the field further down the path of commodification.

Money matters. (Of course it does!)

That $/RVU number is highly variable across the country based on a lot of reasonable and sometimes less reasonable payor and supply/demand factors. High compensation can be from high $/RVU, lots of RVUs, or especially both. Good contracts and stipends can enable very high compensation, especially for highly “productive” radiologists on a productivity model.

The question for any radiologist is what are the costs (if any) for you to optimize for it, and, as a field, what are the long-term consequences to this increasingly nationwide job market and Uberification?

Not everything worth doing has a dollar sign attached to it.