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Supreme Court ruling may pave way to identification of Ontario’s top-billing physicians

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https://www.theglobeandmail.com/canada/article-supreme-court-ruling-may-pave-way-to-identification-of-ontarios-top/

The Ontario doctors who previously charged the most to the province’s health system may soon have their names released to the public, a Supreme Court decision suggested Thursday.

Canada’s top judicial body issued a brief ruling declining to hear an appeal from the Ontario Medical Association and two groups of physicians who have spent years fighting to keep the names of – and amounts charged – by some of Ontario’s top-billing doctors out of the hands of a major newspaper.

The Supreme Court, in keeping with custom, did not release reasons for its refusal to hear the case. But its decision means a 2018 ruling from the Ontario Court of Appeal still stands.

Toronto Star reporter Theresa Boyle had previously made a Freedom-of-Information request to the province’s health ministry for the names of the top 100 physician billers to the Ontario Health Insurance Insurance Plan between 2008 and 2012.

The Ministry of Health made only a partial disclosure and did not include the names or some specializations of the doctors in question.

Boyle successfully appealed to the provincial information and privacy commissioner, who ordered full disclosure of the records on the grounds that the details she sought did not constitute personal information.

The doctors groups then took their fight to court, where subsequent decisions were handed down in Boyle’s favour. The most recent of those came last August when the Court of Appeal – Ontario’s top court – dismissed the challenge from the doctors.

The three-judge panel that heard the case agreed previous decisions had correctly ruled that information such as names and financial details disclosed in connection with professional activities did not count as personal information, since they were distinct from a person’s private life.

“In our view, where, as here, an individual’s gross professional or business income is not a reliable indicator of the individual’s actual personal finances or income, it is reasonable to conclude not only that the billing information is not personal information … but also that it does not describe ‘an individual’s finances 1/8 or 3/8 income,“’ the decision read.

A spokesperson for the Ontario Ministry of health declined to offer specific comment on the Supreme Court’s decision to uphold the Court of Appeal’s ruling, but said the issue of billing disclosure is on its radar.

“The ministry is working with the Ontario Medical Association to look at how physician billings might be disclosed in the future, but those are very early discussions,” said a statement from the ministry.

The Ontario medical Association declined to comment specifically on the Supreme Court decision, but said amounts billed to OHIP demonstrate doctors are performing their duties.

“Every billing represents a distinct health care service delivered to patients in Ontario,” the Association said in a statement. “ … Every billing submitted means one more Ontario resident treated, and one fewer patient waiting for a needed service.”

Toronto Star Editor Irene Gentle cast the Supreme Court’s decision as a victory for government transparency and accountability to the public.

“The Star fought for five years (with several previous rulings in our, so your, favour) for your right to know how your health dollars are spent,” she wrote in a tweet. “The public interest question is settled.”

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Response from OMA:

https://www.oma.org/sections/news-events/news-room/all-news-releases/release-of-physician-billings-data-confirms-high-patient-demand-and-commitment-of-ontarios-doctors/

Release of Physician Billings Data Confirms High Patient Demand and Commitment of Ontario's Doctors

Ontario’s physicians care for more than 300,000 patients every day. They are committed to the health and well-being of every resident of this province. The physician billings released today, as a result of the Supreme Court of Canada’s decision not to grant leave to appeal, clearly shows the demand for health care services and the time, commitment and dedication of Ontario’s doctors to providing this care.

It is important to keep in mind that:

Every billing represents a distinct health care service delivered to patients in Ontario.

These physicians can only bill for every patient they examine, every test they interpret, or every procedure they perform. Every billing submitted means one more Ontario resident treated, and one fewer patient waiting for a needed service. The priority for Ontario’s doctors is to treat and care for more patients, not less.

Ontario’s doctors are committed to working with the Government of Ontario to improve the delivery of care for patients and end hallway medicine.

We are committed to working with government to improve how health care services are delivered to reduce both costs and waiting lists. For example, the OMA recommended and was granted the formation of a joint Appropriateness Working Group.

The amount a physician bills for a service is not their salary or take-home pay.

From their OHIP billings, physicians must pay for professional and support staff salaries, office space, supplies and equipment, all of which are needed to treat patients. On average, these expenses account for 30 percent of the amount billed, however this can be as high as 50 percent.

Ontario patients will continue to be the top priority of Ontario’s 31,500 doctors. We look forward to working with the provincial government and all of our partners in the system to deliver the health care Ontarians need and deserve.

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4 minutes ago, blah1234 said:

No idea why we fought this so hard in Ontario. It's the norm in other provinces. 

"It is our nature" :)

Seriously - sometimes they seem to fight just because they believe they have to oppose the government at every step - probably because there have been some serious and understandable trust issues with doctor vs the government. 

Plus delaying is useful- this is now coming out AFTER we got our new contract and many years prior to the next one. 

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@rmorelan Could you comment on what overhead expenses are usually incurred by the average Radiologists working in a hospital? What about a radiologist who operates a private medical imaging lab? 

I seem to have a grasp on overhead for every other specialty except radiology. Thanks!

Edited by ArchEnemy

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53 minutes ago, rmorelan said:

"It is our nature" :)

Seriously - sometimes they seem to fight just because they believe they have to oppose the government at every step - probably because there have been some serious and understandable trust issues with doctor vs the government. 

Plus delaying is useful- this is now coming out AFTER we got our new contract and many years prior to the next one. 

I'm not sure if delaying had any material benefit given that public perception would've had little impact during the ADR process. This data would've been available to the relevant parties.

I feel all this has done is create the notion that we are against transparency in an attempt to obfuscate our billings. I feel like that is a more damaging narrative to the public. 

Perhaps I'm just too pragmatic as I don't believe in wasting resources to fight losing battles. I feel none of our accreditation/licencing/representative bodies have any degree of budgetary discipline which results in the constant increases in membership fees. 

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Just now, blah1234 said:

I'm not sure if delaying had any material benefit given that public perception would've had little impact during the ADR process. This data would've been available to the relevant parties.

I feel all this has done is create the notion that we are against transparency in an attempt to obfuscate our billings. I feel like that is a more damaging narrative to the public. 

Perhaps I'm just too pragmatic as I don't believe in wasting resources to fight losing battles. I feel none of our accreditation/licencing/representative bodies have any degree of budgetary discipline which results in the constant increases in membership fees. 

I agree it has - and thus I find it a bit silly. Still I know a lot of doctors that really didn't want it to come out prior to that contract and prior to the election.

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1 hour ago, ArchEnemy said:

@rmorelan Could you comment on what overhead expenses are usually incurred by the average Radiologists working in a hospital? What about a radiologist who operates a private medical imaging lab? 

I seem to have a grasp on overhead for every other specialty except radiology. Thanks!

variable which makes it complex - pure hospital people have really low overhead as most of it is run by the hospital.

The problem is clinics - one rad can have on paper huge overhead by both % and number as they may have say a small army of techs under them. Many of the ultra high billers in rads are like that - the ones at 2 million for instance - overhead can be 75% even and sometimes worse. That money is for the techs, equipment and keeping the lights on. If all you do is ultrasound you are trouble comparatively - I know some that make ~300K which for rads is really low as take home, but billings are vastly higher (all those technical fees). Still they don't have call, work weekends, and leave at a predictable time. Could be worse. 

 

 

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What's often left out of a discussion focused on billings/overhead is the amount of work/care that is provided. Hospital-based rads may have fewer overhead expenses than clinic-based; but if patient volumes and higher acuity/complexity are considered, the more intense workloads mean that on an hourly basis, income probably does not differ as much from the other hospital-based physicians that I know of.

Given that in a hospital, we all expect:

1) the imaging department to be running as efficiently as possible to accommodate the volume of studies requested and reduce the amount of time patients have to wait for tests

2) high quality interpretations and reports (which obviously take time to do properly)

3) reports to be released as quickly as possible to support patient care

this means ++after hours work to keep on top of things on a regular basis. Not on call, but last week was working basically from 7 am to 1 am except for a short dinner break, and then continuing over the weekend as the scanners keep running (we are a bit short-staffed right now).  Admin work and meetings (e.g. quality improvement) are also part of a hospital-based practice, but if they can't be scheduled on days off, it means putting off less urgent clinical work to accommodate.

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17 minutes ago, ArchEnemy said:

I have heard that it is a group of several ophthalmologists (~ 10) billing under one physician.

yeah there is a lot of clustering - of the technical fees in particular. This is why some of these billing numbers are practically useless. You are rad billing 3 million? How much of that is to pay for the 20 US techs you have under you, office manager, 2 booking secretaries, a million plus in equipment, office expenses for all of that......so what is left? I don't know, you don't know ha. 

 

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19 hours ago, rmorelan said:

variable which makes it complex - pure hospital people have really low overhead as most of it is run by the hospital.

The problem is clinics - one rad can have on paper huge overhead by both % and number as they may have say a small army of techs under them. Many of the ultra high billers in rads are like that - the ones at 2 million for instance - overhead can be 75% even and sometimes worse. That money is for the techs, equipment and keeping the lights on. If all you do is ultrasound you are trouble comparatively - I know some that make ~300K which for rads is really low as take home, but billings are vastly higher (all those technical fees). Still they don't have call, work weekends, and leave at a predictable time. Could be worse. 

 

 

Thanks for clarifying. Just running some numbers here.

Many of the radiologists at SickKids are salaried and have an annual income of ~$450k (2018 sunshine list). I assume their overhead would be minimal (<5%). This would translate to a pre-tax of ~$430k. 

Physicians who own their practice with 25-30% overhead (Rheum, Endo, Allergy, Derm) bill OHIP ~$375k (before overhead). After 25% overhead, this would be equivalent to a pre-tax $281k.

Now the question is: do the salaried staff radiologists at SickKids work 1.5x the number of hours compared to Rheum, Endo, Allergy or Derm? I suspect probably not (Based on CMA profile, which I know is not the best resource).

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26 minutes ago, ArchEnemy said:

Thanks for clarifying. Just running some numbers here.

Many of the radiologists at SickKids are salaried and have an annual income of ~$450k (2018 sunshine list). I assume their overhead would be minimal (<5%). This would translate to a pre-tax of ~$430k. 

Physicians who own their practice with 25-30% overhead (Rheum, Endo, Allergy, Derm) bill OHIP ~$375k (before overhead). After 25% overhead, this would be equivalent to a pre-tax $281k.

Now the question is: do the salaried staff radiologists at SickKids work 1.5x the number of hours compared to Rheum, Endo, Allergy or Derm? I suspect probably not (Based on CMA profile, which I know is not the best resource).

Oh boy here we go again with another relativity debate haha :lol:

I personally think reimbursement should be tied to health outcomes and the amount of economic value generated rather than just purely measuring hours. However, it is very difficult to attribute outcomes to certain preventative tasks for example. How do you prove that smoking cessation helped prevent a case of cancer from developing if it never develops? This would save the healthcare system a ton but it is very difficult to measure. On the other hand it's pretty easy to measure taking out an appendix before it ruptures as an intervention that generates value.  

It may be that pediatric radiologists, through their reads, generate 1.5x the positive health outcomes that a normal endocrinologist would generate. I think that kind of analysis is going to be riddled with biases and poor data inputs. Income relativity is always a tough subject as I think people want to do what's best for themselves. Though I will say that I have a hard time rationalizing how some fields with the longest hours and the highest acuity (i.e. neurosurgery) are not at the top of the compensation scale in the current system. 

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On 4/12/2019 at 5:26 PM, blah1234 said:

Oh boy here we go again with another relativity debate haha :lol:

I think this thread shows that public perception isn't what we really have to ward against, it's internecine strife (worse in my experience). Given the high demand within our system, it only makes sense that everyone is working hard to provide the best care possible to our shared patient population, and relativity can be approached from a more constructive standpoint. As stated in another thread, I would hesitate to cast aspersions on anyone else's value or hard work, as I could not predict when I might need their particular expertise someday.

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I won't deny that some fields in medicine make significantly more than others for no good reason, but I also don't think it's fair to equate all specialties the same per-hour pay.

An hour of Emerg =/= An hour of Rheum clinic =/= An hour of Neurosurgery operating time

Especially when you start going down that rabbit hole, there's never a fair solution because it isn't obvious which factors should affect income. We don't offer health care in a free market system, so the pay of different specialties is artificial, and highly subjective. Should we consider training time - do you think family physicians should be paid less per hour because they only trained for 2 years, and should specialties that essentially require a fellowship be paid more? Should specialties with a bad job market be incentivized with higher pay? Should specialties ranking unanimously higher on burnout scales be awarded higher pay? Should specialties with irregular hours be reimbursed more? Should specialties that require more resources to function (more allied health, technology, etc.) be reimbursed more?

Actually, specifically to your exact point @ArchEnemy, do you think that clinic pay after overhead expenses should equal hospital pay?

Happy to hear others' thoughts.

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17 hours ago, blah1234 said:

Oh boy here we go again with another relativity debate haha :lol:

I personally think reimbursement should be tied to health outcomes and the amount of economic value generated rather than just purely measuring hours. However, it is very difficult to attribute outcomes to certain preventative tasks for example. How do you prove that smoking cessation helped prevent a case of cancer from developing if it never develops? This would save the healthcare system a ton but it is very difficult to measure. On the other hand it's pretty easy to measure taking out an appendix before it ruptures as an intervention that generates value.  

It may be that pediatric radiologists, through their reads, generate 1.5x the positive health outcomes that a normal endocrinologist would generate. I think that kind of analysis is going to be riddled with biases and poor data inputs. Income relativity is always a tough subject as I think people want to do what's best for themselves. Though I will say that I have a hard time rationalizing how some fields with the longest hours and the highest acuity (i.e. neurosurgery) are not at the top of the compensation scale in the current system. 

 

11 hours ago, Monkey D. Luffy said:

I won't deny that some fields in medicine make significantly more than others for no good reason, but I also don't think it's fair to equate all specialties the same per-hour pay.

An hour of Emerg =/= An hour of Rheum clinic =/= An hour of Neurosurgery operating time

Especially when you start going down that rabbit hole, there's never a fair solution because it isn't obvious which factors should affect income. We don't offer health care in a free market system, so the pay of different specialties is artificial, and highly subjective. Should we consider training time - do you think family physicians should be paid less per hour because they only trained for 2 years, and should specialties that essentially require a fellowship be paid more? Should specialties with a bad job market be incentivized with higher pay? Should specialties ranking unanimously higher on burnout scales be awarded higher pay? Should specialties with irregular hours be reimbursed more? Should specialties that require more resources to function (more allied health, technology, etc.) be reimbursed more?

Actually, specifically to your exact point @ArchEnemy, do you think that clinic pay after overhead expenses should equal hospital pay?

Happy to hear others' thoughts.

Yes, I do think that clinic pay after overhead should be similar to hospital pay, assuming the similar work hours in both cases. In both settings, the doctor is responsible for providing the best level of care to their patients based on evidence within their respective fields. Currently, our system rewards volume rather than health outcomes. There is increasing data showing that as the demographic of physicians shift from predominantly male-dominated to balanced (slightly more females), the volume of patients seen are decreasing, but the health outcomes (readmission rates, mortality rates) are improving. Surely, the higher quality of care should be rewarded? 

The acuity of the patient should not be used as the main surrogate measure of the physician's value, or worse, their income. A neurosurgeon may be very capable at managing an unstable patient with an epidural hematoma, but that same neurosurgeon performing a 60min psychiatry consult for a patient who is acutely suicidal, or a 60 min internal medicine consult for an elderly with aspiration pneumonia and acute CHF exacerbation is probably not ideal. 

There may be administrative roles that physicians in a hospital may have to assume, but likewise with physicians running their own clinic (stock their own supplies, pay their own staff, manage coverage during staff vacations etc). So yes, I do believe that clinic pay (after overhead) should be similar to hospital pay (after overhead).

I believe that hard work should also be rewarded. If a physician does work 1.5x as much their peers, they should be paid accordingly. Unfortunately, releasing the Top 100 physician billings without proper accounting of overhead costs, only serves to penalize these hardworking individuals. 

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6 hours ago, ArchEnemy said:

 

Yes, I do think that clinic pay after overhead should be similar to hospital pay, assuming the similar work hours in both cases. In both settings, the doctor is responsible for providing the best level of care to their patients based on evidence within their respective fields. Currently, our system rewards volume rather than health outcomes. There is increasing data showing that as the demographic of physicians shift from predominantly male-dominated to balanced (slightly more females), the volume of patients seen are decreasing, but the health outcomes (readmission rates, mortality rates) are improving. Surely, the higher quality of care should be rewarded? 

The acuity of the patient should not be used as the main surrogate measure of the physician's value, or worse, their income. A neurosurgeon may be very capable at managing an unstable patient with an epidural hematoma, but that same neurosurgeon performing a 60min psychiatry consult for a patient who is acutely suicidal, or a 60 min internal medicine consult for an elderly with aspiration pneumonia and acute CHF exacerbation is probably not ideal. 

There may be administrative roles that physicians in a hospital may have to assume, but likewise with physicians running their own clinic (stock their own supplies, pay their own staff, manage coverage during staff vacations etc). So yes, I do believe that clinic pay (after overhead) should be similar to hospital pay (after overhead).

I believe that hard work should also be rewarded. If a physician does work 1.5x as much their peers, they should be paid accordingly. Unfortunately, releasing the Top 100 physician billings without proper accounting of overhead costs, only serves to penalize these hardworking individuals. 

Full Disclosure: I am in a field that bills middle of the pack and I'm not defending high/low billers but rather I want to explore the principles behind how we should approach reimbursement

I agree that reimbursements should be tied to health outcomes. I also agree that a neurosurgeon is good at what he is trained in and not so good with other tasks. However, I disagree that if a physician works 1.5x as much as their peers they automatically deserve more money than all their peers just because of more hours. However, I do agree that practically we should compensate physicians who are working significantly harder than the norm as there are flaws in the fee schedule. 

If we look at traditional health economics the 3 basic types of reimbursement for physicians are fee-for-service (FFS), capitation, and salary. The FFS system which the majority of us operate in is great for compensating physicians who work hard but at the cost of measuring patient throughput rather than outcomes. There is also the concern of whether codes between specialties are fair which I will get to later on. I think that FFS by itself, while not perfect, helps reward physicians who are working "harder" than their peers in the same field. I am assuming in this example that most are practicing the standard of care and are seeing consults as fast as safely possible for an optimal outcome.

With regards to fees between specialties, I am approaching this issue from the position of the payer (which in this case would be the government). If I am going to spend $1 of healthcare funding I would want to spend it on the intervention that returns the most value. In this case, I hope that every $1 of reactionary or preventative intervention brings the most amount of savings that I would otherwise incur from not treating a patient (while also accounting for the time value of money). There's no perfect metric out there but if you want to use QALY, DALY or whatever hybrid methodology you can quickly see that not all services are valued equally. Some part of this may be the difficulty in tying outcomes to specific actions like preventative medicine as I mentioned in my previous post. Through this, I don't believe from a resource perspective we should be looking at equality or equity from the viewpoint of a physician's take-home income, but rather if a resource input into physician 1 will deliver more output than physician 2. Now, this is oversimplifying things as we should also use fees to prevent the deincentivisation of certain fields and to ensure that students still studying them.  I believe this framework stemming from researchers like Dr. Olsen show that there is the theoretical case that a specific physician working 30 hours a week could be delivering more economic value to society than a physician working 80 hours a week and thus be compensated more. Practically speaking I don't think the reality is quite that extreme but we should still be cognizant how our services should not be equally valued which could explain many of the disparities in the fee schedule. I do think that currently we prioritize measurable interventions like procedures over things like counselling which leads to the current distribution of specialties on the billing spectrum.  

I use acuity as a dimension (although not the only dimension) because the value of treating high acuity cases can mean the difference between life and death for a patient which has a huge impact in many health outcomes metrics. It is acuity in combination with other factors that generate the worth of a physician to society and thus their compensation in this single-payer system. I think as physicians we are obviously concerned with how much take home income we are making instead of straight gross billings, however, I don't think we should be the primary stakeholder or consideration when deciding how to allocate healthcare dollars. Likely we'll have to start blending payment models rather than rely purely on FFS to reimburse physicians.

Happy to hear your thoughts on the matter. 

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On 4/12/2019 at 9:44 PM, Lactic Folly said:

I think this thread shows that public perception isn't what we really have to ward against, it's internecine strife (worse in my experience). Given the high demand within our system, it only makes sense that everyone is working hard to provide the best care possible to our shared patient population, and relativity can be approached from a more constructive standpoint. As stated in another thread, I would hesitate to cast aspersions on anyone else's value or hard work, as I could not predict when I might need their particular expertise someday.

Unfortunately, at least in my province, we have had issues with salaried physicians (in multiple specialties) really just dialing it in and working at 25%-50% or so of their average ffs compatriots in the specialty while drawing a full salary. Things like seeing only 4 follow ups a day when the ffs people were seeing 10 or more. 

Now the province has started really cracking down on those people, forcing them to see an appropriate amount of patients, so hopefully, things will improve. 

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1 hour ago, NLengr said:

Unfortunately, at least in my province, we have had issues with salaried physicians (in multiple specialties) really just dialing it in and working at 25%-50% or so of their average ffs compatriots in the specialty while drawing a full salary. Things like seeing only 4 follow ups a day when the ffs people were seeing 10 or more. 

Now the province has started really cracking down on those people, forcing them to see an appropriate amount of patients, so hopefully, things will improve. 

ha, well that is predictable

there is also what you mean by appropriate - right now some people on FFS I think reasonable feel they are moving at extreme volume - that isn't about the money, it is about the pressure from long wait lists and clinical demand. Radiology would actually fall into that category - our output per day has at least by informal analysis doubled in the past 15 years and that isn't from the tech advances. You go salary and you better believe people will slow down - in their eyes back to a sane level which is safer for patients. 

I don't expect any government body to see a reduction as positive mind you ha. 

Edited by rmorelan

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4 hours ago, rmorelan said:

there is also what you mean by appropriate - right now some people on FFS I think reasonable feel they are moving at extreme volume - that isn't about the money, it is about the pressure from long wait lists and clinical demand. Radiology would actually fall into that category - our output per day has at least by informal analysis doubled in the past 15 years and that isn't from the tech advances. You go salary and you better believe people will slow down - in their eyes back to a sane level which is safer for patients. 

I don't know if it would be possible to slow down due to the high clinical demand. Although I have heard of unread studies piling up in other jurisdictions due to physician shortages, at the hospitals I've worked at in this region, there is an expectation that ER examinations be reported within an hour or two. Our hospital also has a report turnaround time policy (being discussed) that if routine exams are not signed off in a certain number of days, the issue can be escalated to the Site Chief and Medical Affairs as it is considered that patient care is being impacted.

I've heard the same thing from pathologists under salary - they are being asked to do more and more volumes, which can make it difficult to maintain high quality of work and avoid burnout. Even if the employer doesn't hold us accountable for volumes, there is pressure from other services to decrease turnaround times, as of course they are also under their own pressures to manage patients, facilitate discharges and so forth.

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10 minutes ago, Lactic Folly said:

I don't know if it would be possible to slow down due to the high clinical demand. Although I have heard of unread studies piling up in other jurisdictions due to physician shortages, at the hospitals I've worked at in this region, there is an expectation that ER examinations be reported within an hour or two. Our hospital also has a report turnaround time policy (being discussed) that if routine exams are not signed off in a certain number of days, the issue can be escalated to the Site Chief and Medical Affairs as it is considered that patient care is being impacted.

I've heard the same thing from pathologists under salary - they are being asked to do more and more volumes, which can make it difficult to maintain high quality of work and avoid burnout. Even if the employer doesn't hold us accountable for volumes, there is pressure from other services to decrease turnaround times, as of course they are also under their own pressures to manage patients, facilitate discharges and so forth.

realistically possible ha - probably not. But you would have, like with, a disconnect at least on some level between various goals of people (rads vs admin). Plus now we have pathology as an example of hose things can go sideways as well and we hope not to repeat it. One of the reasons rads has made so much is the explosion in the need for imaging frankly driving us a bit nuts with volume. THere is just this never ending pool of stuff to read - and never a "light day" as it were, never any down time. The scanners are run to max capacity constantly, with each study getting more and more complex - more recontructions, more slices, new techniques ha. Messy. 

 

 

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