Workload in radiology: Why should we care?

Headlines such as ‘Radiologists’ happiness has plummeted‘ and ‘Almost half of private practice rads experience burnout‘ resonated with us. Workforce shortfall, increasing volumes of imaging, and backlogs have taken a toll on radiologists’ personal lives.

Besides bringing back memories of the pressures of the job, we also wondered how someone outside of the profession would perceive such news. And so we asked around; the answers did not reassure. ‘Sounds like sensational journalism‘ or ‘Wait, how is that even safe?‘

Based on conversations with practising radiologists and the experience of a former radiology registrar, we are providing some context as to why radiologists are overworked, what the impact is, and what we can do about it. We’re using data from the UK, but the challenges mentioned are shared by radiology departments in many other countries.

A never-ending stack of images

The demand for medical imaging is rising faster than most other aspects of healthcare. The latest census from the Royal College of Radiologists (RCR) indicated a 5% annual growth in demand for diagnostic activity, with no sign of plateauing.

How do we explain the increase in images? There are some major contributors:

• The ageing population. People live longer and tend to require more imaging to assess their health.
• Technology advances. We’re better equipped to perform targeted diagnostic scans and to find more, subtler abnormalities.
• Developments in clinical practice. We have more ways to treat severe diseases, such as cancer, and imaging is required to monitor treatment responses.
• New imaging-based screening programmes. They enable early detection and prognosis but drastically increase the number of images.
• “Defensive medicine”. A trend deemed significant by Dr Giles Maskell, referring to our society’s tendency to reduce uncertainty by deploying more imaging and tests.

The workforce shortfall

The crux of the issue is that there aren’t enough radiologists to manage the volume of medical images generated in our healthcare systems.

The same RCR census showed a meagre 3% growth in the clinical radiology workforce, against the 5% growth in imaging and the pre-existing shortfall. The current staff shortage in the UK is 29%, expected to rise to 40% in five years without intervention.

But beyond all these figures, what does an actual day in the life of a radiologist look like?

A radiologist’s timetable

A typical week in the life of a radiologist might look like this. Most radiologists’ job plans are individualised, so this timetable isn’t a one-size-fits-all model.

Nonetheless, if you’ve worked in a radiology department, you will recognise two sets of tasks:

Reporting images

The radiology specialisation uses medical imaging to diagnose and treat illnesses and injuries. And that, of course, requires more than just looking at the image. A scan reporting process might include these steps:

• Ascertain the patient’s clinical history, including the reason for the scan;
• Review previous relevant imaging;
• Interpret the current scan;
• Create a report of the findings;
• Communicate the report to the referring physician, either through PACS or directly.

Non-reporting tasks

Many people see radiologists solely as image reviewers, confined to their dark rooms and removed from patient interaction. Yet there is so much more to their work. Radiologists do assess medical images, but their role is more complex.

Our experience is that more than half of a radiologist’s time is spent on non-reporting tasks, namely:

• Prepare and attend multidisciplinary team meetings (MDT), where physicians, oncologists, pathologists, and other specialists, come together to make clinical decisions about the most appropriate next step in the management of each patient.
• Communicate findings to patients and discuss the course of action.
• Act as ‘Doctor of the Day’, performing tasks such as answering the phone to discuss requests for urgent scans; reporting urgent cases; vetting, justifying and protocolling imaging requests.
• Perform interventional procedures, e.g., image-guided biopsies.
• Supervise registrars by reviewing and amending their reports before they are released to clinicians or supporting their training by explaining techniques of viewing and interpreting scans.
• Support professional activity, a mix of administrative work, emails, non-urgent referrals or requests to review images.

A big time-consumer is the preparation and attendance of MDTs. Through discussion involving multiple specialists, MDTs facilitate joint decision-making in order to improve patient outcomes and promote standardised practice. Before the meeting, radiologists review all relevant imaging and reports to present pertinent findings to non-imaging specialists. This requires double work.

While undoubtedly adding value to the meetings, are we really improving the overall quality of care by cutting down the time allocated to report routine cases? In radiology interviews, questions like ‘What is the role of the radiologist in MDTs?’ and ‘Are MDTs a good use of our time?’ are still a subject for debate.

The consequences

With the current imaging volumes, workforce constraints, and daily reporting and non-reporting tasks, radiologists are under immense pressure; there are not enough hours in the day to finish all the work. Some physicians will have to work extra, skip lunch, or come in on a weekend.

This is not sustainable in the long term. 100% of the clinical directors surveyed for the RCR census are worried about staff morale and burnout in their departments. It is, in this context, not surprising that an above-average number of consultants left the UK workforce in 2022, at a younger age than average.

To cope with the excess reporting, health systems are also incurring additional costs – £223 million in the case of the UK in 2022, according to RCR.

The impact on the quality of patient care is unavoidable; only a quarter of clinical directors said they had sufficient staff to deliver safe and effective care.

Ongoing interventions

The problem outlined above isn’t new. The RCR predicted these challenges many years ago. The ongoing surge in medical imaging requests has resulted in interventions to manage the overload.

Expanding training and fellowship strategies, also a recommendation of the RCR census. In some trusts, radiographers are trained to interpret and report certain images, e.g., MRI knees and chest X-rays.

Insourcing and outsourcing. In some trusts, radiologists are paid by the NHS to work extra sessions to reduce some of the backlogs. In others, scans are sent to third-party companies, who report the scan and send the report back to the trust. Outsourcing, however, comes with limitations, such as costs and the re-reporting workload.

Auto-reporting, which implies identifying which examinations could be reported by non-radiology staff and sending an automated response to referrers. This message informs them that the examination will not receive a formal radiology report and that it is their responsibility to provide one. We’ve seen departments where some X-rays are only reported if specifically requested, e.g. orthopaedic MSK X-rays.

Artificial intelligence (AI) is on most radiologists’ radars by now, and the NHS is becoming one of its leading supporters and implementers. Most of the sites reporting in the Targeted Lung Health Checks, NHS England’s flagship lung cancer screening programme being rolled out nationwide, are using AI for lung nodule management. The AI award is accelerating the testing and evaluation of the most promising technologies, e.g. the INPACT programme. The latest NHS Long Term Workforce Plan highlights the promising results achieved so far and the expectation for AI to free up clinical time and improve accuracy and efficiency.

The progress in AI makes us hopeful that we are not far off gaining experience and confidence in developing and using tools to perform tasks better suited to machines.

Urgency and hope

Radiology is often the starting point of the care pathway and is fundamental in diagnosis and treatment. Thus, the high workload in radiology has a severe human impact, not just on practitioners but also on patients and society.

Our clinical radiologists have the best insight into the workforce crisis and should be involved in the conversation about how improvements can be made. Engagement from radiologists would help guide areas that need to be prioritised and ensure the sustainability of changes.

With innovations such as AI, the future of radiology can be exciting rather than uncertain. If your radiology team is dealing with a high workload, look into adopting AI. Start by reaching out – we’ve deployed lung nodule reporting tools in 100+ hospitals, and we can see you through!