I’m working my tail off but not getting any work done (Part 2 of 3)

The Quantum Unit of Work, the Time Tax and the Productivity Formula

In my previous post, I detailed factors contributing to the extremely labile stress levels that we feel as radiologists — specifically feeling so busy but finding it difficult to get any “real” work done. Being so busy yet, paradoxically, having a concomitant plunge in productivity. I broke down the causes of this phenomena into the following categories:

1. The normal ebb and flow of patient volume.
2. Fires.
3. The Dump.
4. Complex cases.
5. Not being “present.”
6. Team not being “present.”
7. Broken systems.

I also promised to explain the ideas of the Quantum Unit of Work (Q) and the Time Tax (Tt) and how they interact with each other. We’ll do that right now…and then dive into a formula that details the relationship between productivity and all of these variables. I had previously promised to do this in two parts…but I lied. Because of the broadness and complexity of this topic I ultimately decided to break this into three parts. I think the punchline will be worth it.

The Quantum Unit of Work

Like a seamstress, we get paid by the piece. There is no such thing as partial work, and we don’t get partial payments. Every study you read has a minimum amount of time that must be spent on it from start to finish. Of course, some studies take longer to read, and on some days you are able to read faster than others, but the general concept is unchanged. There is a minimum, non-zero, amount of time it takes to open an exam, read the pertinent history, systematically scroll through the images, compare them to priors, generate a report, and close the case.

Certainly, that time varies for different exam types. A screener chest X-ray requires vastly different commitments of time and energy compared to a CTA with bilateral lower extremity runoffs…but for any given study, there is a quantum unit of time that must pass before you can be “finished” with that study and move on to the next one. This is especially true for cross-sectional exams.

This minimum time block to read a study in an optimized situation is what I call the Quantum Unit of Work (Q). It determines your maximum reading rate. Now, in an ideal world, we would all be blazing through our worklists, ringing that reimbursement bell for every Q that passes. But we live in reality…and in reality, there is a Time Tax.

The Time Tax

The Time Tax (Tt) is the cumulative cost of all of those interruptions that slow our productivity to a crawl. There is a real likelihood that any/every single study on your worklist has a certain amount of time that you’ll have to spend on it that is unrelated to the work of actually “reading and reporting” it. That time, averaged out per study, is the “Time Tax”. The “Time Tax” is hungry and your “productivity” is its lunch.

Some examples of the time tax would include the time that it takes to speak to someone who calls about the position of an NGT on a chest X-ray, the time it takes to review a CT scan for the appropriateness of a drainage procedure, the time it takes to talk to staff about a pending procedure, the time it takes to call in a critical result, etc. Furthermore, it also includes the time it takes to disengage your train of thought when you are interrupted from reading an exam and the time it takes to re-engage your brain and regain your train of thought — a known and documented cost associated with “multitasking”.

I believe a measurable time tax exists for every study on your worklist, whether you have read it or not. To go deeper, the time tax actually has persistence (tail) and antecedence (nose) in that you can get calls about previously reported studies and questions about studies that haven’t yet been performed. But for the sake of simplicity, the Time Tax can be compressed into a single number for every study on the active worklist. The definition of when a study is active is up for discussion but we’ll define it as the period from when a study is performed to when the report is finalized. The largest share of the time tax is likely “paid” in the active and peri-active period.

Time Tax, meet Worklist

It’s obvious that as the Time Tax increases, we become less productive; what is less intuitive is that the Time Tax is synergistic with the number of studies on the list. On days where the list is long, you’re more likely to have interruptions related to the cases on that worklist…and your productivity will plummet accordingly. I’ve always noticed that things seem crazier when my list is long to begin with…or when the list starts off short but becomes long very quickly.

Let me give you a few scenarios to help explain these relationships more concretely.

Scenario 1:

Assume that all you have on your list are generic CT exams, if, at your fastest (good day, no interruptions, nothing), you are able to read 12 per hour, then the Q would be 5 minutes per case. So if you were working alone for 5 hours with the door locked, phone unplugged, steady IV infusion of coffee or Red Bull, and no interruptions…you should be able to bang out 60 studies in 5 hours.

For this scenario the time tax is zero. The assumption is that there were no interruptions or ancillary things to do for the exams.

Scenario 2:

Now let’s assume that your time tax was 1 minute for every exam. If you only had 12 studies on your list, then after an hour, instead of reading 12 studies, you would have spent 12 minutes dealing with interruptions and would have only read a total of 9 exams…that’s a significant drop from 12.

Scenario 3:

So let’s make things more interesting. Say you arrive at work and there are 40 exams on the list and we are assuming no exams are being added to the list — a static list. The phone calls start from the get-go. So now you’ll spend, on average, 40 minutes of that first hour dealing with these interruptions and you’ve only read 4 studies. Say hello anxiety.

Scenario 4:

With the time tax of 1 minute per exam, you reach a breaking point when you have 60 exams on the list. You spend 60 minutes dealing with interruptions…you’ve been frustratingly busy for an hour…and you haven’t been able to finish reading even one exam. An hour has passed and there are still 60 studies on the list waiting for you!!! You’ve been working hard, but have literally not done any “work”.

Scenario 5:

What if the time tax is now doubled to 2 minutes? Then with all things being equal, you would reach the “breaking point” with only 30 exams on the list.

Some points:

* The idea of a static time tax, of course, is an oversimplification but I think it can be a useful idea/metric.

** In real life, few of us would have a static worklist. Exams would be piling up and if you are at or near the “breaking point,” then you could start to go backwards…the list explodes and you feel like you are drowning. I’ve definitely experienced this. Your only hope is that there is a “lull between sets” or you will end up having to stay late or having to dump on your colleagues.

The Productivity Formula

The nerdy side of me has taken the liberty to transform this theory into a formula. This isn’t just “cute” — this formula provides a way to visualize the relationships that I’ve been talking about, and also gives us a way of thinking about how to tune “productivity” in a systematic manner. Here is the most simple version:

P = ((60 — (Tt * N)) * e ) / (Q)

P = Productivity = cases per hour

Tt = Time Tax (in minutes)

Tt = Ti1 + Ti2 + Tf

Ti1 = Time spent dealing with any random interruption that is part of the work of being a radiologist.

Ti2 = Time spent by a radiologist dealing with interruptions that could have been dealt with by someone else.

Tf = Time spent to disengage/regain focus when you are interrupted in the middle of reading a study.

N = Number of studies on your worklist.

e = the elasticity factor for how fast you are reading (0–1). It is not a measure of interruptions (which is included in variables above); rather, it is more a measure of the radiologist’s internal focus and how mentally efficient he or she is on that day compared to their optimal state. It is a measure of how “present” you are. 1.0 is reading at your fastest sustainable pace when you are mentally focused and in a flow state…Of course, e is usually well below 1.0 (at least for those of us who are not robots).

Q = Quantum unit of work (minutes). We are referring to a generic situation, as this would certainly vary drastically by exam type, the radiologist doing the reading, the complexity of the case, etc. Also, it is a number that can change over time…for instance, a radiologist becoming more efficient or familiar with PET/CT will require less time to read those kinds of exams. Nevertheless, the fundamental idea is unchanged. Going below your Q is possible but probably means you are flirting with malpractice. Our work isn’t infinitely incremental. If you require 5 minutes to read a specific exam in ideal conditions, any further decreases in time would require unacceptable sacrifices of quality or accuracy.

Therefore, the final formula*** is:

P = ((60 — ((Ti1 + Ti2 + Tf) * N)) * e ) / (Q)

** This is still a simplified formula. For the sticklers, I’ve included a more accurate, but more complex, formula in the appendix below.

SUPERCHARGING YOUR PRODUCTIVITY

We’ve taken a general look at the components of productivity and their relationships with each other. This gives us a framework to systematically explore each variable and how tweaking those variables may affect productivity in the radiology workplace. As a thought exercise, let’s dive a little deeper into the first two variables, Ti1 and Ti2, of the productivity formula, as they are the most straightforward.

In Part 3 I’ll break down the remaining four variables and how their interaction helps to create that feeling that I described in my first post, feeling extremely busy but unproductive at the same time.

Ti1 — Interruptions that are inevitable and part of your job as a radiologist. The reality is that what we do is much more than just about generating reports. Unfortunately, this is not accurately captured in the reimbursement structure (a discussion for another time). Part of what we do will always, and should always, be done with the dictaphone down. For instance, in my opinion, direct one-on-one consultation with clinicians should, with rare exception, be done directly by the radiologist. This is part of our service and just good business. You should not try to minimize Ti1…in fact, there is an argument that a good group would seek to maximize this to the point of diminishing returns.

Ti2 — These are interruptions that are not, or should not, be falling into the lap of the radiologist. These are things that the radiologist gets pulled into because staff have not been trained adequately or appropriate systems have not been put into place. This includes a lot of what was categorized as “Broken Systems” in Part 1 of this post. For example, calls forwarded to you by the front desk asking about what type of prep to give to a patient for a fluoro study, or the front desk running n

ormal lab values by you for an upcoming procedure…and then having the technologist in charge of the procedure also interrupting you to see if you have seen the same normal lab values.

This is a huge topic that deserves its own in-depth post(s). Put simply, there should already be systems and protocols in place so that these interruptions don’t ever arrive at the desk of a radiologist. If you’re getting interrupted to deal with things that CAN be dealt with by someone else, then they should be dealt with by that “someone else.” That “someone else” can be a number of people, including technologists, physician assistants, nurses, front desk staff, radiology supervisors, and hospital administrators. Also, in this world of blossoming technological solutions, it is increasingly possible that those things can and should be dealt with by someTHING else.

So that is a lot to digest so far. I’ll pause here. In Part 3 I’ll finish diving in on the remaining four variables of the productivity formula (Tf, e, N, Q). This will uncover an important feedback loop that, I believe, is a major contributor to our stress as conscientious radiologists. Stay tuned.

*** APPENDIX

Here I’ll go into a more nuanced version of the Productivity Formula that I presented earlier. It basically unpacks the Time Tax, pulling out the nose and tail.

We are assuming constant inflow volume

P = [ { 60 — ((Tt nose * V) + (Tt tail * RR) + (Tt active * N)) } * e ] / Q

Tt nose = Time tax exacted in the now by exams that have not been performed yet.

Tt active = Time tax exacted in the now by active exams on worklist that are awaiting a read or being read. This period ends when the exam is closed and report crosses over.

Tt tail = Time tax exacted in the now by studies that have been reported (i.e. reviewing exams for tumor board). All exams have a “curing” period over which the likelihood that that exam will require further attention from the radiologist will fade over time. You are more likely to spend time talking to a physician about an exam performed last month than an exam performed 3 years ago. Tt tail is just the sum of that time averaged out on a per exam basis.

Helpful to think of each of the three categories of time tax as consisting of the three separate components mentioned in first formula. Therefore:

Tt nose = Ti1 nose + Ti2 nose + Tf nose

Tt active = Ti1 active + Ti2 active + Tf active

Tt tail = Ti1 tail + Ti2 tail + Tf tail

V = total active imaging studies ordered (all the studies on deck)

I = Inflow = V / Scan rate

N = I — P

RR = recently read volume. This is just a measure of how many exams have been read in the recent past. It is just a reflection of the fact that a radiologist who is in a busy practice and has read twice as many cases in the past week is twice as likely to have to reattend to some of those cases than a radiologist who read half as much.

e = has a dynamic relationship to N. So as the stress levels go up, our e will adjust. At most simple level, as the N goes up, stress goes up, and we adapt by reading faster…but the reality is that sometimes it can be the opposite, where we maladaptively read less productively (the throwing up of hands). The other thing that sometimes happens with a busy worklist is that our per exam read time can drop below Q, which is not safe.