By Dr. Raj Chopra

When I attended last year’s RSNA conference, one topic was consistently discussed: what is equitable distribution in radiology workloads? What constitutes “equitable and fair?”

For a long time, relative value units (RVUs) have been the benchmark for determining which cases get assigned to which radiologists. RVUs are important for revenue and the practice's financial health, which I recently noted will take on even greater importance this year.

But is RVU everything? Could it be doing more harm than good?

Workload distribution is burning people out. I hear too often about radiologists who feel like they’re taken advantage of in their practices, that they’re doing more work than others, and that their work isn’t valued as highly since it generates less revenue. Recent research revealing some radiologists may be paid the same amount, regardless of the number of images they looked at for a procedure, further highlights the risks for unfairness (or perceptions of unfairness) in this system.

RVU has been the foundation for how imaging practices assign workloads to clinicians, but doing something out of familiarity isn’t a good reason to keep doing it indefinitely. If RSNA 2025 was any indication, we’re ready to rethink how we distribute workloads – moving away from an entirely RVU-based system to a more holistic workflow orchestration that assigns cases more fairly and creates more equitable work for radiologists.

RVUs can be a double-edged sword for practices
The American Medical Association gives a relatively high RVU value to newer breast imaging studies. Obviously, breast imaging is a critically important area of care that has had significant positive effects on patient care – the double-digit decline in breast cancer mortality in the U.S. is due in part to the increased use of breast imaging. Breast imaging helps save lives and, in turn, also generates a lot of revenue for practices.

But many other clinicians are doing just as hard work – screening for cancers, tumors, and lesions – who don’t get comparable levels of RVU equity. This work involves strenuous, time-consuming levels of patient care, and the clinicians reading those studies experience the same level of burnout as everyone else. But their work doesn’t count for RVU on the same level, so it’s perceived as “less important.”

If you’re a radiologist examining a patient with cancer, comparing multiple priors to track any changes in the disease takes more time than, say, reading a head CT scan or MRI. If you assigned workloads based strictly on RVU, then these critical cancer cases could remain on the list for days, potentially even weeks, before a doctor’s review. That’s not only untenable; it’s deeply unacceptable for our profession. And think about what this means for patients. We want to run practices where we feel we’re making a difference in our patients’ lives. How does it help patients to think that their exams may be waiting to get picked up because they may be perceived or valued as more or less necessary by the RVU system?

You need both kinds of clinicians – the ones doing the more RVU-friendly work and the ones reading the less “glamorous” studies – to make a practice work. It’s not just about running a holistic practice; it’s also about running a successful one where clinicians are happy. There isn’t a lot of happiness or job satisfaction to be found in spending hours per day reading studies that are vital to the patient, but that the RVU formula dictates as simply not as important.

To make workloads more equitable, take people out of the equation
Workload distribution should take RVU into account. But it shouldn’t be the sole factor determining which cases get assigned to which doctors. Complex problems require compromise solutions – in this case, a hybrid approach that minimizes, and maybe even removes, people from the study allocation process.

Why exclude people? We’re all human beings, we all have biases, and we all get angry when we perceive bias as positively aiding one person and negatively affecting another. The friction around RVUs and workload distribution is already grounded in the perception that some get preferential treatment based on the value or volume of cases assigned.

One way forward is to consider workflow orchestration technology that distributes cases not solely based on RVU but on multiple factors, like age, diagnosis, urgency, the clinician’s specialty, the number of studies already assigned to them, and so on.

Cases are matched to the clinicians with the most relevant skills and expertise rather than cherry-picked based on personal preference.

Radiologists share more even levels of caseloads, reducing both the risk of burnout and the perception of bias.

Clinicians also receive more equitable compensation, so no one is seen as benefiting more than others.

Patients’ exams are read and prioritized by order of urgency rather than more arbitrary RVU-driven reasons.

This is just one idea, but it’s one I believe has the potential to assign workloads more fairly to radiologists. Fairness, along with the reduced perception of human bias that goes with it, can go a long way toward making physicians feel happier, more fulfilled, and less burned out.

You don’t necessarily need a fully automated, machine-driven approach to this problem. I know one practice that created a committee with outside consultants that set up a new RVU review process to assign cases. But if the idea of bias is creating tension and feelings of unfairness among clinicians – which in turn exacerbates our industrywide burnout problem – then automating workload distribution can go a long way in eliminating this perception of bias. As I often heard at RSNA, “I want a machine to do this so there’s nobody to blame.”

In an RVU world, no one is king of the castle for long
Perhaps the best argument against an RVU-centric system is the acknowledgment that RVUs aren’t forever. You may be king of the castle today, but it could be someone else tomorrow. We’ve all seen one specialty or another rise from the bottom of the list for RVUs to the top or were ranked at the top and, at some point, fell from that perch. With the emergence of more innovative imaging technologies, this status quo is guaranteed to see another shake-up at some point. When that happens, and your specialty falls on the list, do you still want to work in an RVU-only world?

Radiology is contending with a serious crisis of burnout and staff shortages. To make it through this crisis, we, as a profession, need to rekindle a sense of community in our work. We’re clinicians, not independent contractors; we’re supposed to all be on the same team, working as one holistic practice. The feelings of bias and friction from unfair workload distribution, exacerbated by RVU metrics, threaten to unravel that sense of community – not to mention the patient-first, care-first mentality that all physicians work tirelessly to keep as their #1 priority.

Looking for a world past RVUs only – automating workflow orchestration to ensure that cases are assigned more fairly and everyone shares in the benefits and the work as equally as possible – is a major opportunity to reinvigorate that communal feeling and make it stronger than ever.

About the author: Raj Chopra, MD, is the Chief Medical Officer for Merge by Merative. He has over 20 years of clinical experience as a board-certified radiologist. He has been actively involved in various advisory roles, helping to guide many organizations on imaging AI, FDA regulations, billing and coding, claims processing, utilization reviews, and Medicare/Medicaid compliance.