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?

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