Moore's Law for Radiologists

Most radiologists have heard of Moore’s Law. It was named after Gordon Moore, co-founder of Intel. In 1965 he observed that the number of components on a microchip had been doubling every year. He also predicted that this would continue for at least ten years. In 1975, he revised this to every two years. Rather oddly, this has been uncannily accurate for the intervening fifty years..

A close colleague observed that radiologists are affected by a type of Moore’s Law. The amount of scans a radiologist is expected to shift per day is increasing year on year. Not doubling every two years but expectations are steadily growing. Today’s radiologist is expected to shift work at an eye-watering rate. Our forebears would weep at the modern pressure of expectations.

When I was in short medical trousers, I grew up surrounded by mighty plain film gods. They would sit at the banks of lightboxes, their hands in constant motion as the films went up and down in a fluid motion, merely skimming the surface of the brightly illuminated surfaces, staying still for a few femtoseconds as the report was barked onto tape.

And they did this alarming juggling act for hour after hour, day after day, demolishing huge piles of film packets. Some of my radiological heroes would report a staggering 30-40k radiographs a year. I still don’t know how they did it. Well, apart from an impeccable work ethic and having done it so often, they were operating on basal ganglia most of the time. The neocortex rarely had to engage. They truly were on autopilot.

Then CT and MR went mainstream. But they were thankfully slow. Anyone remember scanners that took a minute per single slice? 20s rotation, 40s reconstruction. To cover a CT and MR ‘list’ was a luxury; it was to escape the murderous fluoroscopy rooms, IVU lists and indeterminable piles of plain films

Then the scanners got fast. The scanners could reconstruct images faster than we could report them. Scanners operated early morning, late evening and at the weekends. More scanners were installed but few radiologists were employed. Slowly but surely scanning capacity was divorced from reporting capacity. I remember the crossing of this particular radiological Rubicon; about fifteen years ago in here in the UK.

So what happened? Well, radiologists had to up their game. They had to report faster and work longer hours. But that only butters so many parsnips. Particularly in the NHS, where radiologists are salaried and have decent employment rights. So their monopsony employer could only thrash them lightly. Whereas those that are paid by the scan were not spared the managerial birch twigs.

So radiologists started dropping duties. So as to report more CT and MRI, radiologists stopped doing hands-on ultrasound and fluoroscopy. Some even [startled gasp] gave up report plain radiographs. Many diagnostic radiologists became pure CT and MRI specialists.

Radiologists also stopped doing paperwork. They stopped vetting and protocolling scans. They stopped checking their reports. This was all delegated. They were pure lean, mean CT reporting machines.

But the pressure kept building, the numbers of CT and MRI grew by 20% annually in my hospital. Radiologists then started a new tactic: hiding. The only way they could appease the Gods of Cross-Sectional Imaging was to avoid contact with other humans. By locking doors, retreating to hard-to-find PACS stations, giving up clinical meetings, not answering phones or emails, radiologists found they could get more cross-sectional done. Working from home ticked all these boxes. Radiologists got called antisocial, rude and grumpy but they could cope with that, so long as the CTs and MRIs got read.

And yet the workload expectation grew. The next tactic that radiologists used to cope with burgeoning workload was ergonomics. It is true that productivity can be improved by improving the environment in which a radiologist works. The advent of sit-stand desks, mandatory air conditioning, 4 point adjustable chairs and voice recognition software actually that worked all made a small improvement to productivity.

But expectations kept growing. A good day five-ten years ago was reporting forty cross sectional imaging studies. You’d be happy with that, walk out with a spring in your step, a solid day’s work behind you. Now that would be an average day. It is not unusual to hear of radiologists expected to report seventy plus scans a day. This is entails a ten-twelve hour day, five days a week.

When you sit back and look at what has happened to radiology over the last twenty years, how much it has changed and it’s all about servicing the massive burden of CT and MRI reporting. Some of this is, of course, good. We understand so much more about the human body, disease and how to detect it accurately via cross sectional means.

But we’ve ripped the heart of what it means to be a radiologist. Gone are the polymaths, the generalists who can turn their hand to anything. Gone is any semblance of control over our workflow. Gone is the popular and approachable radiologist that clinicians would seek to discuss cases.

And it’s caused an epidemic of burnout. Barrelling through CT and MRI like a video game, barely looking at the images purely to get on to the next case isn’t why we became doctors. It’s almost entirely devoid of meaning and singularly lacking in fulfilment. No wonder radiologists are browned off.

The worst thing about it? We’ve been played. It happened right in front of us, on our watch. We’ve been taken for suckers. And it is going to be mighty hard to stop or even reverse the radiological Moore’s Law of reporting. Or as I shall name it, Kelly’s Rule of Radiology Reporting, after my friend Barry Kelly who got me onto this topic.

But stop this we must. It is unsustainable. It is unsafe for our patients. It is absolutely ripping the heart out of our beautiful speciality. Quite how we do so is another question.

New Book Out!

My second book "More Rules of Radiology" is now out!

You can get it from any major physical or online retailer. The quickest is probably direct from the publisher, Springer

From the back cover:

"Based on the social media success of my series of articles around ‘The Rules of Radiology’ this follows on from the first volume (‘The Rules of Radiology’), published in 2021. ‘More Rules of Radiology’ is the second and final volume that contains Rules 51-100. The Rules provide a guide to what radiology is and what radiologists do. Or rather what radiology should be and what radiologists should do.

This book and its prior sister volume looks hard not just at radiology but also provides a distinctly wry look at the curious and occasionally alien world of hospital-based medical practice. I ask questions and poke fun but it is serious intent. My motto is ‘first make you laugh, then make you think’. Or, as George Bernard Shaw wrote, “My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity”.

Each of the Rules addresses an important part of professional practice. I analyse the underpinning concepts of modern radiology, critically reflect on underlying assumptions, pose thoughtful questions and provide measured debate. All sprinkled with a mixture of weak jokes, puns and gratuitous word play.
As a relatively young but rapidly expanding specialty, there has been no guide for radiologists, no moral compass. Until now. I provide opinions and guidance on key matters; sometimes controversial but always reasoned. The hope is to provide the reader with much food for thought. Not only that but this volume and its predecessor aim to provide a manifesto for radiologists across the globe to raise their game and serve their patients better."

The Juniors are Revolting

The UK’s Society of Radiologists in Training (SRT) has just published the highlights of it’s 2024 training survey. It landed on social media as an infographic and made quite the splash. Although it only featured the preliminary results, it makes for ugly reading.

Many are withholding official comment until the full data is released. Plus the results should be viewed with caution as the 202 radiologists in training that were surveyed represent just ~15% of the UK’s total. Notably, 1/3rd of these trainees were from the North of England and a further 1/3rd were from London and the South East. I’m not saying the radiology training in those locations is considerably worse but, well, it might be.

It isn’t all doom and gloom. 64% were satisfied or very satisfied with their training, which, for a bunch of Gen Z-ers, is a win. Plus the majority felt that they’d be taken seriously if their raised concerns about their training. And this is on a background of radiology being one of the most popular specialities, with an 11:1 competition ratio for applicants: radiology training places. So they arrive fairly motivated, you would expect.

There is also a societal context: Brits like nothing more than complaining. It is a national pastime. Being quick to judge, quick to anger and slow to understand are, sadly, widespread traits in these Isles. Plus it has always been that the young to judge their seniors negatively and vice versa. The old see the young as feckless and lazy; the young see the old as repressive dinosaurs. It’s a tradition, an old charter or something.

But the general tone of these results is very depressing. Recent changes to the Royal College of Radiologist’s training curriculum were viewed negatively by the majority. 61% felt pessimistic about the future of radiology training in the UK. Even increases in training places was seen negatively by 44%. Which is paradoxical but perhaps understandable.

The major beef, as presented, is that non-radiologists are increasingly being trained to do what would typically be considered radiologist’s work, specifically the training of Physician Associates (PAs) and Reporting Radiographers (RRs). Although only 10% had worked with PAs, there was unanimous condemnation that they had a negative impact on their training. A slim majority also felt that RRs already had a negative impact on training in plain radiograph reporting and the vast majority felt the RRs reporting cross sectional imaging has a negative impact on their training and that further expansion should be resisted.

Despite the potential for bias, these results cannot be ignored. And, together with similar results from recent training surveys by the British Medical Association (BMA), Association of Surgeons in Training and Doctors Association of the UK, a consistent picture emerges of young doctors across the UK. The picture is one of vanishing training opportunities and marked disgruntlement.

This dissatisfaction is so pronounced that 78% of respondents to the SRT survey stated they were more likely to leave given the current expansion and extended practice of non-Radiologist roles. When nearly 8 in 10 of your trainees want to leave, the prospect is horrifying. Eerily it is almost identical to what 3819 junior doctors said in the BMA survey from December 2023: 79% said that they often think about leaving the National Health Service.

Understanding why the UK’s junior doctors are in revolt isn’t complex. Pay has been massively eroded over the last 14 years, resulting in ten rounds of industrial action thus far. Sadly there is no end to this industrial action in sight with government paymasters holding steadfast. Debt amongst medical graduates has never been higher and the UK’s cost of living crisis grinds on. Plus working conditions in the NHS have never been more demanding, with widespread staff shortages and spiraling demand.

This isn’t to say that the plight of radiologists in training is irredeemable and intrinsically linked to the woes of the NHS. But it is difficult to envisage and easy solution when looking at the existing body of consultant radiologists. There is a much-publicised and long-standing consultant radiologist shortfall. And, as ever, when time is short and work-lists are long, training is the first to suffer. In our local patch at least, individual consultant trainers are doing their best with what little time they have.

Obviously an increase in pay for trainees would help. Life is easier if you aren’t both poor and miserable. It might seem self-evident but exploiting each and every training opportunity is vital. Plus radiology trainers should very visibly prioritise the learning of radiology trainees over other staff groups. The next generation of radiologists will suffer if the current generation pulls the ladder up behind them. Without these measures, we will be in a deeper hole than ever before.

But whilst the government and higher echelons of the NHS are wailing that, “There is no money for training or pay increases", you can’t help feeling a rising level of despair and it is no wonder that our current trainees are eyeing up Australasia and North America for their tertiary careers. If I was in their shoes, I’d be doing exactly the same.