avoid private equity?

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newlife2020

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I always saw people talking about avoid private equity on the forum, like you work more for less in PE. But salary wise, they are pretty good, starting salary even close to partnership salary in private practice. Can someone elaborate more on the downside of working for PE? less of autonomy? too high volume? poor quality service? Thanks!

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Private equity has positive returns for investors by skimming off the top of the professional reimbursement. In some markets that might be okay, because the large presence of the PE group in a particular location may mean it can negotiate better insurance reimbursement rates than the smaller private practices, but for the most part you’ll probably still be making less than a similarly productive partner radiologist at a physician owned private practice, at best.

Other word I heard is while their employed positions can be decent (in terms of $salary/annual wRVU), their “partner positions” are a little better, but not by much, certainly not enough to match the $salary/annual wRVU for a partner radiologist.

Might be worth working for if you want to be eminently mobile, beholden to no one, work 100% remote and change your schedule up however you want at a moments notice, and forever remain employed. But if that’s not you, and my suspicion is for vast the majority of people, that if it’s you currently it won’t be you forever, I strongly recommend passing.

If only because if the radiology market ever turns, you can be damn sure they will be the fastest to financially screw you. Because to them you are an expendable commodity, nothing more.

Use them to leverage better pre-partner pay at a true private practice if you want to. But that’s the only thing I’d use them for. PE is the bottom feeding lamprey of medicine.
 
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I always saw people talking about avoid private equity on the forum, like you work more for less in PE. But salary wise, they are pretty good, starting salary even close to partnership salary in private practice. Can someone elaborate more on the downside of working for PE? less of autonomy? too high volume? poor quality service? Thanks!
You are contributing to the downfall of your own specialty by joining them.

When there is a rad shortage sure they can pay similar to anyone else, but their duty is to literally skim money from you. In any specialty once they gain a monopoly on employment they will worsen the skim on your $$$ and raise RVU targets so you grind more than ever.
 
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If you haven't seen content from Ben White's blog, you should check it out. He's young career rad in a hybrid group in Dallas who has posted several articles on PE in radiology and lays out a lot of the considerations.





 
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It's not a good job for being mobile either because of the extensive noncompetes.
 
It is not black and white. It is a spectrum.

Generally speaking a private practice partnership job is better. But there are lots of caveats:

1- Some private practices have long partnerships. 4-5 years. If that's the case there is no significant difference between a PE Job and a private practice job in the first 10 years or so of your practice.

2- Some private practices are not efficient. I have seen it closely. There are lots of senior partners who are very slow and read only certain modalities. Also their contract consist of bad payer mix. They have a bad IT infrastructure. It takes forever to get hold of a referring physician. The techs are not good so the quality of studies suck. They do a disproportionately high number of low paying studies like lots of fluoro, lots of Xrays, lots of drains and biopsies and lines and lots of cancer follow up studies.

3- In some private practices the studies are cherry picked by certain radiologists and you are stuck with bunch of hard studies to read.

4- In a typical private practice, as a DR you have to subsidize the salary of IRs. Also you have to go to hospital committees and do some non-paid duties. Also depending on the practice set up you may end up doing a lot of weekends and evenings.

So if you consider all these factors, in a lot of private practices you are practically giving away 20% or so of you salary.

So it is possible that a PE Jobs turns out to be as good or even better than a real private practice job. But the top 30-40 % of private practices are generally better than a PE job.
 
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Recently I did a per diem work for a private group for a week.

This was what happened:
- they paid me 1.5 times per RVU compared to telerad. Greeaaat!!
- I could not work from home.
- Their PACS was good.
- I was interrupted by techs every 15 minutes or so for simple questions.
- I had to do a simple procedures which paid peanuts between my cases. A simple drain or a simple arthrogram took a lot of my time because of inefficacy of the whole system.
- The ultrasounds did not have good tech notes. The notes were long and vague.
- A good number of studies were oncology imaging that took a lot of time. Later I found that they do a disproportionately high number of Cancer imaging.
- Getting hold of a referring physician was a nightmare.
- I had to answer a lot of phone calls from other physicians and PAs who had questions about other reports.

Just saying that if I worked for telerad, I could make 30-40% more by spending similar amount of time and getting annoyed less.
 
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telerad and/or pay per click options are always going to be a fundamentally different proposition than onsite PP.

Alot of those negatives listed about PP still occur in PE-backed PP, only the financial upside is lower. But yes, direct comparisons of jobs need to be made (as best as possible).
 
My general advice is don't work for a private equity group if at all possible. In today's job market, I don't see any reason why you would.

Even if you want to be maximally flexible for lifestyle and time off, you can have the same flexibility if not better with some private practices. Some private practice groups will offer partnership for overnight telerad jobs. Other groups will offer employed telerad positions for very high $$$/hour rate. You often can trade shifts with other partners in the group for more flexibility. Just look on the ACR job board for these types of jobs.

Private equity groups often play with RVU numbers by using their own internal RVU numbers that are slightly worse, so that you end up getting paid less for the same work. They also can and will change the pay at a moment's notice if the supply of radiologists goes back up. Many times your contract is not for a guaranteed salary - it might say "pay rate can change at any time with 30 days' notice" or something to that effect. And as Ben White documented, the stock shares of private equity groups don't mean anything if the group goes bankrupt.

TL;DR: If you're going to be employed telerad or 1099, at least do it for a private practice where your bosses are other radiologists, and you can make similar money.
 
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A stupid newbie question, radiology partners are private equity, right? it seems that there are so many practices are under RP now.
Also it seems that some NY/NJ private practice even after partnership, the income is only a little bit higher or similar to an employed position say for example an academic position. Why is that? So then why do people still prefer private practices which of course have high volume compared to academic practices.
 
A stupid newbie question, radiology partners are private equity, right? it seems that there are so many practices are under RP now.
Also it seems that some NY/NJ private practice even after partnership, the income is only a little bit higher or similar to an employed position say for example an academic position. Why is that? So then why do people still prefer private practices which of course have high volume compared to academic practices.

Yes, RP is private equity. It's probably the single largest PE-backed group right now.

The money delta between PP-partnership and academics should be decently substantial (ideally $200k above at least), but other reasons include no teaching responsibilties, no research, less non-clinical responsibilities, more vacation, easier case-mix.

Some people in academics count their CME weeks as vacation time, which is sorta true in that you're free from clinicals, but i'd rather just be straight off.

The volumes in academics are definitely coming close to PP in some instances.

There's an overall blurring of comp/productivity between certain PP's and academics, whereas 15 years ago the two were very distinct.
 
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A stupid newbie question, radiology partners are private equity, right? it seems that there are so many practices are under RP now.
Also it seems that some NY/NJ private practice even after partnership, the income is only a little bit higher or similar to an employed position say for example an academic position. Why is that? So then why do people still prefer private practices which of course have high volume compared to academic practices.

RP certainly has a large presence currently but next few years will be telling with respect to their long-term viability. Also perception maybe skewed as many/most job openings are RP/private equity as these are sub-optimal and difficult to fill/retain.

I've worked in CA, tristate, and midwest. The only PP job I had that had academic income had 3 day work weeks. The tristate PP was upper 6 figures for partners. Of course it was a higher volume job. Vacation also tends to be much more generous in PP, and there is much more say in how things are run. Also less internal politics though this still exists in PP, particularly as group size increases.

Academics however can be a sweet gig (more so in mid-west/southeast) though volume is certainly climbing.

Bottom line for any job is compensation/wRVU +/- benefits. This def gets more blurry in academics/employed positions since money can get shuffled around between departments based on demand.
 
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The delta between private equity and a well-run private practice is enormous, but may not be evident on a short time horizon.

Local PE groups advertise $5-550k to start with 10 weeks vacation. Compared to mid-300s as an associate in PP with 8 weeks vacation it looks fantastic and probably does come out ahead on a <5 year timeline. But after 2 years and becoming partner our PP income skyrockets to nearly $1M with equivalent vacation and lower yearly RVU volumes. The $/wRVU for our practice is double that of the PE group and there is additional income from real estate, technical fees, etc. If you know where you want to live long term and know you aren’t afraid of the higher workload of PP/PE then it’s not even close.

Certain PP can be poorly run where this math doesn’t pan out or local supply/demand forces can increase what PE has to pay to get rads but broad strokes a “good” PP will beat the pants off a “good” PE. To boot you maintain autonomy in how you practice, how you want to balance income/lifestyle, and have a sense of pride in owning the practice. By definition a PE group is doing everything they can to maximize their profit on your back. They want to pay as little to Rads as market forces will allow. To me, even if the total compensation is good I couldn't work in an environment in which I know the MBAs see me as a revenue generator and nothing else, patient care be damned.

Yes, there are extra responsibilities in running a practice. Yes there are headaches. Yes there are things that are unpaid but required. Yes there is a required substantial physical presence in the hospital. In the scheme of things these are not a big deal and easily worth it.
 
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The delta between private equity and a well-run private practice is enormous, but may not be evident on a short time horizon.

Local PE groups advertise $5-550k to start with 10 weeks vacation. Compared to mid-300s as an associate in PP with 8 weeks vacation it looks fantastic and probably does come out ahead on a <5 year timeline. But after 2 years and becoming partner our PP income skyrockets to nearly $1M with equivalent vacation and lower yearly RVU volumes. The $/wRVU for our practice is double that of the PE group and there is additional income from real estate, technical fees, etc. If you know where you want to live long term and know you aren’t afraid of the higher workload of PP/PE then it’s not even close.

Certain PP can be poorly run where this math doesn’t pan out or local supply/demand forces can increase what PE has to pay to get rads but broad strokes a “good” PP will beat the pants off a “good” PE. To boot you maintain autonomy in how you practice, how you want to balance income/lifestyle, and have a sense of pride in owning the practice. By definition a PE group is doing everything they can to maximize their profit on your back. They want to pay as little to Rads as market forces will allow. To me, even if the total compensation is good I couldn't work in an environment in which I know the MBAs see me as a revenue generator and nothing else, patient care be damned.

Yes, there are extra responsibilities in running a practice. Yes there are headaches. Yes there are things that are unpaid but required. Yes there is a required substantial physical presence in the hospital. In the scheme of things these are not a big deal and easily worth it.
If “associates” start at mid 300s and partner make nearly seven figures, the practice sounds like a predatory pyramid scheme. Does this group have 4 years to partner, and >1/2 of them go through this period only to be offered continued associates status without ever actually getting partnership? The only thing that is more of a bottom feeder than PE is such a group.
 
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If “associates” start at mid 300s and partner make nearly seven figures, the practice sounds like a predatory pyramid scheme. Does this group have 4 years to partner, and >1/2 of them go through this period only to be offered continued associates status without ever actually getting partnership? The only thing that is more of a bottom feeder than PE is such a group.

Groups like those can and do exist but I feel like they're a lot less common place now. 1) PE knocked out alot of the big groups in desirable places 2) there's such an overall shortage of rads that any rad you onboard you need to do your best to keep around.

The whole 'churn and burn' mentality doesn't work well when the costs of onboarding/credentialing are crazy high and the supply of available rads is super low.

You def still have to do your homework though.
 
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Totally get that some bad PP are out there. You should always do your due diligence in talking to prior associates who didn’t make partner, current associates, etc. My point was that strong PP still exist that far outweigh what PE has to offer if you’re willing to make an upfront investment. No self-respecting business is going to put a new hire on equal footing in terms of voting and profit sharing from day one. Our partnership track length is 2 years, which is in line with the rest of the current market and frankly pretty reasonable. If you take the mindset that these type of setups don’t exist or worse think anything presenting itself as such can only be predatory, then you will not find such a practice. If you go into the job hunt open-minded but pragmatic/cautious and network like crazy early in residency then you will find lots of opportunity. It’s important that residents know these jobs do exist but won’t be advertised and actually require a lot of effort to obtain.
 
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If “associates” start at mid 300s and partner make nearly seven figures, the practice sounds like a predatory pyramid scheme. Does this group have 4 years to partner, and >1/2 of them go through this period only to be offered continued associates status without ever actually getting partnership? The only thing that is more of a bottom feeder than PE is such a group.

To add on: the scenario described is a real one but I think a lot of caveats should be added, cuz even in your scenario ~1/2 of the people are making it through and will join the partnership and be able to make nearly seven figures. If you told a group of residents that if they signed with this hypothetical group out of training they would have a 50% chance of making $1m per year, i think a fair number of them would try.

I've worked in two big groups that made high 6 figures (approaching 7 several years). Both of which formerly had long partner tracts and large buy-ins.

There were people in both who didn't make it to partner. In almost every case, the people in question were told that their speed was concerning at the 6-12mo period and that they needed to speed up before they'd be considered for partnership. Some of those people left immediately, knowing they either couldn't or didn't want to. Many stayed cuz the upside of partnership was worth the attempt but ultimately didn't progress fast enough to be offered partnership, but as you said were either offered continued associate status/employee status. A few actually were able to make changes to the partnership's expectations and were happily accepted into the partnership without reservations.

In any event, my take home point is that if you're a trainee/junior rad and you hear that XYZ group makes high 6's/low 7's but that a number of associates don't make it.... it's not necessarily because the group is predatory/bottom feeding. High 6's/low 7's is 90th plus percentile compensation. You should expect to produce 90th plus percentile production. Many people cannot and/or do not want to do that. Understand there's no free lunch. If you weren't a devourer of lists in residency you prolly won't do well in a high volume, high compensation group.
 
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To add on: the scenario described is a real one but I think a lot of caveats should be added, cuz even in your scenario ~1/2 of the people are making it through and will join the partnership and be able to make nearly seven figures. If you told a group of residents that if they signed with this hypothetical group out of training they would have a 50% chance of making $1m per year, i think a fair number of them would try.

I've worked in two big groups that made high 6 figures (approaching 7 several years). Both of which formerly had long partner tracts and large buy-ins.

There were people in both who didn't make it to partner. In almost every case, the people in question were told that their speed was concerning at the 6-12mo period and that they needed to speed up before they'd be considered for partnership. Some of those people left immediately, knowing they either couldn't or didn't want to. Many stayed cuz the upside of partnership was worth the attempt but ultimately didn't progress fast enough to be offered partnership, but as you said were either offered continued associate status/employee status. A few actually were able to make changes to the partnership's expectations and were happily accepted into the partnership without reservations.

In any event, my take home point is that if you're a trainee/junior rad and you hear that XYZ group makes high 6's/low 7's but that a number of associates don't make it.... it's not necessarily because the group is predatory/bottom feeding. High 6's/low 7's is 90th plus percentile compensation. You should expect to produce 90th plus percentile production. Many people cannot and/or do not want to do that. Understand there's no free lunch. If you weren't a devourer of lists in residency you prolly won't do well in a high volume, high compensation group.

What is the typical daily and yearly wRVU for a high production group? In our employed setting (tertiary level I trauma center), we average 55-60 wRVUs/day with pay just above 2020 MGMA medians. Can make more if you take call or moonlight. Call volumes can be 70-100 wRVU. We already feel very busy, so can’t imagine what it is like to read at a pace that would generate low 7 figure compensation. That seems painful, and I suspect they are probably missing a lot in those high volume practices.
 
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If you weren't a devourer of lists in residency you prolly won't do well in a high volume, high compensation group.
Any advice to the rising R1 who may not be in the highest volume residency?
 
What is the typical daily and yearly wRVU for a high production group? In our employed setting (tertiary level I trauma center), we average 55-60 wRVUs/day with pay just above 2020 MGMA medians. Can make more if you take call or moonlight. Call volumes can be 70-100 wRVU. We already feel very busy, so can’t imagine what it is like to read at a pace that would generate low 7 figure compensation. That seems painful, and I suspect they are probably missing a lot in those high volume practices.

I think it can vary a lot. At minimum you're looking at prolly 80 wRVU per day if not higher. I've heard some high-earning groups want 90-100. depends on how much time off they take.

If you just take a ballpark of the math backwards, you can figure it out. Say one of said groups does about $45/wRVU after all expenses. $1m/$45/rvu -> 22.2k RVU's. If their contracts are a lil' worse and they do $40/rvu then you're talking 25k.

I have absolutely zero doubt some of my partners are doing 20k+ rvu's per year. I don't choose to work at that pace nor make that extra moonlighting money.

For reference, i believe the average overall rad production in the country is about 11k+ RVUs. The VA asks for like 5 or 6k minimum.

As yes, I've seen some of my partners miss a lot. And the quality isn't great.
 
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Any advice to the rising R1 who may not be in the highest volume residency?

Speed can be trained. It's very hard to overcome being a **** rad.

Focus on being the best resident you can. See as many cases as you can, as much pathology as you can, and learn as much as you can. You'll build your search pattern over time; that'll allow you to go faster later. As your knowledge base grows, you'll intuitively start to know what's important and not important. That allows you to go faster because you're not staring down an unknown finding for 10min or dictating a paragraph on a benign finding.

Good luck
 
Some people never become fast readers even after many years of practice.
3-4 months after joining our practice, I can say who will be a fast reader and who will not 4 years down the road.
 
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The biggest enemy of being a good radiologist is OCD trait. It decreases the quality of the report (10 different differentials) and also it decreases the speed significants.
 
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To add on: the scenario described is a real one but I think a lot of caveats should be added, cuz even in your scenario ~1/2 of the people are making it through and will join the partnership and be able to make nearly seven figures. If you told a group of residents that if they signed with this hypothetical group out of training they would have a 50% chance of making $1m per year, i think a fair number of them would try.

I've worked in two big groups that made high 6 figures (approaching 7 several years). Both of which formerly had long partner tracts and large buy-ins.

There were people in both who didn't make it to partner. In almost every case, the people in question were told that their speed was concerning at the 6-12mo period and that they needed to speed up before they'd be considered for partnership. Some of those people left immediately, knowing they either couldn't or didn't want to. Many stayed cuz the upside of partnership was worth the attempt but ultimately didn't progress fast enough to be offered partnership, but as you said were either offered continued associate status/employee status. A few actually were able to make changes to the partnership's expectations and were happily accepted into the partnership without reservations.

In any event, my take home point is that if you're a trainee/junior rad and you hear that XYZ group makes high 6's/low 7's but that a number of associates don't make it.... it's not necessarily because the group is predatory/bottom feeding. High 6's/low 7's is 90th plus percentile compensation. You should expect to produce 90th plus percentile production. Many people cannot and/or do not want to do that. Understand there's no free lunch. If you weren't a devourer of lists in residency you prolly won't do well in a high volume, high compensation group.
I suppose it depends on how transparent you are about the failures of desired associates to attain partnership status with applicants. But most groups don't want to share who was an associate and failed to get partner, and how many there were. So frankly, as reasonable as you seem to make it sound, my opinion is such groups rationalize their approach as egalitarian, while simultaneously fooling naive new grads by obfuscation and misleading. Let's say a new grad is 1.5 years in, the group doesn't like their quality / quantity... do you tell them immediately that they won't make partnership status? You wait another year, they haven't changed... do you tell them now?

Of course not. You let them keep chugging, subsidizing your income for you, and then at the four year mark you break the tough news. They bounce, new associate, rinse and repeat.

A polished turd is still a turd. If you're ripping 30-50% off the top of a young rad with statistically unlikely promises of a golden future, you are no different than the PE guys. Especially because 7 figures is such a high income (significantly above 90th percentile), I don't care how fast you read or how good your contracts are, someone is subsidizing you. Either the hospital, or the new grad labor.

Maybe I'm just a jaded cynic, but after seeing how the majority of practices treated new grads during the hellpit from '08-'15, I really don't have faith in rad practice leadership whatsoever in their ability to look out for anyone's interest but their own. Idgaf how they rationalize it.
 
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What is the typical daily and yearly wRVU for a high production group? In our employed setting (tertiary level I trauma center), we average 55-60 wRVUs/day with pay just above 2020 MGMA medians. Can make more if you take call or moonlight. Call volumes can be 70-100 wRVU. We already feel very busy, so can’t imagine what it is like to read at a pace that would generate low 7 figure compensation. That seems painful, and I suspect they are probably missing a lot in those high volume practices.

As someone already mentioned, around 11/12K wRVU/year is prob median for PP. I don't recall where I got this info, but remember hearing that 17/18K wRVU is around 90th%....For daily production you would obviously need to know total # of normal work day shifts and call shifts.

As a side note you are in a tough setting (my PP group covers tertiary level 1 trauma, stroke center) when it comes down to volume/burn-out etc. Cases can be really complex. Infinitely easier to read higher volumes in community type practices. Also reading breast (tomo screeners in particular) is a great way of generating high wRVUs.

Very hard to read enough volume to hit low 7 figure comp (I'm referring to take home pay, not total package of benefits, profit sharing etc). Would need to be over 20K wRVUs unless the group had fairly high comp/wRVU (most PP are between $50-70/wRVU)
 
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Some people never become fast readers even after many years of practice.
3-4 months after joining our practice, I can say who will be a fast reader and who will not 4 years down the road.

What’s fast? I can read a normal CT abdomen pelvis with contrast in 4-6 mins, depending on how easy it is to exclude mesenteric masses or nodules. But I have seen some people read these in 2 mins. That’s very fast but not sure how safe that is.

Complicated staging CT belies can take 15-20 minutes to read and properly compare to prior PETs and old CTs.
 
What’s fast? I can read a normal CT abdomen pelvis with contrast in 4-6 mins, depending on how easy it is to exclude mesenteric masses or nodules. But I have seen some people read these in 2 mins. That’s very fast but not sure how safe that is.

Complicated staging CT belies can take 15-20 minutes to read and properly compare to prior PETs and old CTs.

Being fast does not necessary mean you are not provided a good quality report or you are doing something risky.
I have seen people take 15 minutes to report a case of appendicitis.

I understand that being too fast can be risky. But most slow readers claim that the fast readers are not good or safe which is not true in many cases.

As I said, I feel there is something in people's personality that makes them fast or slow. Off course over time people get faster and better.
 
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Being fast does not necessary mean you are not provided a good quality report or you are doing something risky.
I have seen people take 15 minutes to report a case of appendicitis.

I understand that being too fast can be risky. But most slow readers claim that the fast readers are not good or safe which is not true in many cases.

As I said, I feel there is something in people's personality that makes them fast or slow. Off course over time people get faster and better.

There’s definitely a bell curve to speed/quality.

More cases does sharpen your eye and search pattern for normal/abnormal over time. Up to the point where you’re skipping more and more stuff in the name of time.
 
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What’s fast? I can read a normal CT abdomen pelvis with contrast in 4-6 mins, depending on how easy it is to exclude mesenteric masses or nodules. But I have seen some people read these in 2 mins. That’s very fast but not sure how safe that is.

Complicated staging CT belies can take 15-20 minutes to read and properly compare to prior PETs and old CTs.

>17K wRVUs/year or >70 wRVU/shift (8-9 hours) would be considered fast from my perspective if one was reading a general mix...Our breast imagers are around 80-90 wRVU/shift or 18-19K wRVU/year in a moderately busy PP...When I have a screener day I can read at a leisurely pace, around 60 tomo screeners and hit around 70wRVU. This is vastly different from reading mix of outpts (anything from oncology CT c/a/p to prostate MR). Much more soul sucking and inefficient from a wRVU perspective.
 
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Being fast does not necessary mean you are not provided a good quality report or you are doing something risky.
I have seen people take 15 minutes to report a case of appendicitis.

I understand that being too fast can be risky. But most slow readers claim that the fast readers are not good or safe which is not true in many cases.

As I said, I feel there is something in people's personality that makes them fast or slow. Off course over time people get faster and better.

I've worked in about 5 diff PPs and have seen all sorts of rads and their reports. Fast vs slow readers is an interesting topic. Def associated with personality type. Each category contains subsets. There are fast readers that focus on the important big picture findings and there are fast readers that are just sloppy/lazy (eg. recommending f/u imaging for something that was present years ago on a different imaging exam/modality). Slow readers can also vary. Some are super meticulous, compare/correlate with any prior study, and overly report things and some are not that meticulous but for whatever reason still slow....Also agree that rads can get faster/better for multiple reasons
 
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