Rationale and Objectives
To compare programs with and without 24-hour/7 days a week/365 days a year (24/7/365) in-house radiologist coverage regarding resident perceptions of their on-call experience, volume of resident dictations on call, and report turnaround time.
Materials and Methods
Residents from six academic radiology departments were invited to participate in an 11-item online survey. Survey items were related to workload, level of autonomy, faculty feedback, comfort level, faculty supervision, and overall educational experience while on call from 8 pm to 8 am . Each site provided data on imaging volume, radiologist coverage, volume of examinations dictated by residents, number of residents on call, and report turnaround time from 8 pm to 8 am . F-ratios and eta-squares were calculated to determine the relationships between dependent and independent variables. A P value < .05 was considered statistically significant.
Results
A total of 146 (67%) of 217 residents responded. Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage.
Conclusion
More rapid report turnaround time related to 24/7/365 coverage may come at the expense of resident education.
A 2007 survey conducted by the Society of Chairs of Academic Radiology Departments showed that 10% of responding institutions had 24-hour in-house coverage by faculty radiologists . The conclusion from this survey was “coverage by attending radiologists around the clock is not the current standard of practice at most academic medical centers.” A series of surveys conducted by the American Alliance of Academic Chief Residents in Radiology (A3CR2) showed that the percentage of academic radiology departments with 24-hour/7 days a week/365 days a year (24/7/365) in-house radiologist coverage had gradually increased from 4% in 2002 to 7% in 2004 to 14% in 2005 (dropping slightly to 12% in 2009) up to 20% in 2012, with an additional 7.5% planning implementation by 2013 . The justifications for expansion of radiologist coverage into areas traditionally handled by radiology residents alone have included: 1) increased imaging service expectations from emergency medicine and trauma surgery physicians 2) positive impact of immediate finalization of radiology reports (eg, decreased patient recall rates) , 3) past reports of frequent significant discrepancies between interpretations by radiology residents and radiology attendings , 4) potential “turf battles” over control of emergency imaging , and 5) the need to link the attending activities with nighttime coverage of other vital inpatient activities (eg, intensive care unit image interpretation). Arguments against the expanded role of the radiology attending focus on the lack of recent evidence of significant discrepancies between interpretations by radiology residents (especially senior level) and radiology attendings for either medical or traumatic emergencies, often accompanied by recommendations to not deprive the radiology resident of a valuable experience in professional autonomy .
The 2008 report of an Institute of Medicine committee on resident duty hours strongly endorsed greater supervision of residents, stating “the committee found that closer supervision leads to fewer errors, lower patient mortality, and improved quality of care” . Increased faculty presence could serve to counter the “hidden curriculum,” which substantially affects resident perceptions of supervision and may act as a barrier to requesting assistance, even when it is clearly necessary . The risk to such a system includes the potential to undermine resident autonomy.
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Materials and methods
Site Data
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Survey
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Statistical Analysis
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Results
Site Data
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Table 1
Site Data
Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 MD FTE 44.6 32.4 56 49 95 118 Residents 27 33 30 38 44 45 Examinations ∗ 48,169 20,110 9387 70,600 36,640 55,634 Resident dictated † 14,768 8,820 7114 40,670 36,640 38,746 24/7/365 ‡ Yes Yes No Yes No No Limited nighttime § All subspecialty until 8 pm , then general coverage Neuroradiology until 8 pm , nonneuroradiology general coverage 5 pm to 8 pm Neuroradiology until 9 pm No Yes, 6 pm –3 am Yes, at one site until 10 pm Residents after 5 pm 1 resident 5–8 pm , 2 residents 8–2 am , 1 resident 2–7 am , no resident (attending only) 7–8 am 2–3 residents 5–9 pm Monday-Friday, 2 from 9–8 am 7 days a week 1 junior resident (radiographs) 4:30–10 pm ; 1 senior resident (CT/US/MR/radiographs after 10 pm ) 4:30 pm –7:30 am 3 until 9:30 pm , 2 until 2 am , 1 until 8 am 3 residents: one junior (radiographs and fluoroscopy) and 2 seniors (cross-sectional) 4 No face to face ‖ Yes Yes No No Yes Yes Time to staff out ¶ 3.5 h (all cases); ED cases 0.5–1.0 h 2–45 min Staff-out occurred in the morning; therefore, up to 15 h 2–45 minutes Junior residents: before 12 am a few minutes, later up to 9 h. Seniors: before 3 am a few minutes to an hour. Later, 1–12 h. 9– 12 h TAT # 3.2 h (ED cases 0.5–1.0 h) 34 min 11 h, 24 min 45 min 3.7 h 12 h Target TAT ∗∗ 80% within 2 h <1 h 24 h 30 min radiographs; 45 min CT ED 2–4 h; inpatient 12 h ≤10 h
CT, computed tomography; ED, emergency department; FTE, full-time equivalent; ICU, intensive care unit; MD, physician; MR, magnetic resonance; TAT, turnaround time; US, ultrasound.
Note: The order of the institutions on the survey and Table 1 are not necessarily the same.
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Survey
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Table 2
Comparisons of Sites with and without 24/7/365 Coverage on Items from the Resident Survey
Item 24/7 Coverage F Ratio ( ∗ P < .05) Eta-Square (Proportion Variance Accounted) Yes Mean (SD) n No Mean (SD) n What percentage of examinations is dictated by residents between 8 pm and 8 am ? 4.1 (0.9) 76 3.7 (1.4) 71 3.20 0.02 How often are you the primary contact for referring clinicians between 8 pm and 8 am ? 4.4 (0.8) 78 4.6 (0.7) 69 1.67 0.01 How would you rate the appropriateness of your level of autonomy between 8 pm and 8 am ? 3.6 (0.9) 78 4.5 (0.9) 69 33.48 ∗ 0.19 How would you rate the adequacy of feedback from faculty radiologists between 8 pm and 8 am ? 3.8 (1.0) 78 3.3 (1.2) 68 7.92 ∗ 0.05 How often are you able to research questions during initial review of radiologic studies between 8 pm and 8 am ? 3.3 (0.9) 78 3.3 (0.8) 69 0.11 0.00 How would you rate your comfort level in performing duties between 8 pm and 8 am ? 3.8 (0.9) 78 3.8 (1.0) 68 0.63 0.00 The degree of faculty supervision between 8 pm and 8 am attracts candidates to this residency program 3.4 (0.9) 78 3.7 (0.9) 69 3.04 0.02 How would you rate your overall educational experience of nighttime call between 8 pm and 8 am ? 3.6 (1.0) 78 4.2 (0.8) 69 13.23 ∗ 0.08
SD, standard deviation.
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Table 3
Comparisons of Sites with and without 24/7/365 Coverage by Resident Level
Item 24/7 Coverage R1 Mean (SD) n R2 Mean (SD) n R3 Mean (SD) n R4 Mean (SD) n R5 Mean (SD) n Eta-Square (Proportion Variance Accounted) What percentage of examinations are dictated by residents between 8 pm and 8 am ? Yes 4.4 (0.7) 20 3.9 (0.8) 16 4.0 (1.0) 23 3.9 (1.0) 17 — Res = 0.05 Cov = 0.01 Inter = 0.01 No 4.4 (0.8) 12 3.6 (1.6) 16 3.8 (1.4) 20 3.4 (1.4) 20 3.67 (2.3) 3 How often are you the primary contact for referring clinicians between 8 pm and 8 am ? Yes 4.3 (1.0) 21 4.3 (0.8) 16 4.5 (0.7) 23 4.5 (0.6) 17 — Res = 0.08 ∗ Cov = 0.02 Inter = 0.01 No 4.4 (0.7) 10 4.7 (0.4) 16 4.7 (0.5) 20 4.6 (0.5) 20 3.3 (2.1) 3 How would you rate the appropriateness of your level of autonomy between 8 pm and 8 am ? Yes 3.7 (0.8) 21 3.9 (0.7) 16 3.6 (0.8) 23 3.3 (1.2) 17 — Res = 0.3 Cov = 0.18 ∗ Inter = 0.04 No 4.2 (0.9) 10 4.4 (0.9) 16 4.6 (0.6) 20 4.6 (0.7) 20 4.7 (1.3) 3 How would you rate the adequacy of feedback from faculty radiologists between 8 pm and 8 am ? Yes 3.8 (0.9) 21 4.0 (0.8) 16 4.0 (0.9) 23 3.6 (1.2) 17 — Res = 0.03 Cov = 0.07 ∗ Inter = 0.03 No 2.8 (0.9) 10 3.1 (1.4) 16 3.6 (1.0) 20 3.5 (1.1) 19 3.7 (1.3) 3 How often are you able to research questions during initial review of radiologic studies between 8 pm and 8 am ? Yes 3.3 (0.7) 21 3.5 (0.8) 16 3.6 (1.0) 23 2.8 (0.9) 17 — Res = 0.05 Cov = 0.00 Inter = 0.14 ∗ No 2.6 (0.5) 10 3.2 (0.6) 16 3.2 (0.7) 20 3.8 (0.7) 20 2.0 (1.7) 3 How would you rate your comfort level in performing duties between 8 pm and 8 am ? Yes 3.3 (0.7) 21 4.1 (0.7) 16 4.3 (0.7) 23 3.9 (1.1) 17 — Res = 0.28 ∗ Cov = 0.02 Inter = 0.07 ∗ No 2.6 (0.5) 9 3.4 (0.9) 16 4.0 (0.6) 20 4.4 (0.6) 20 3.7 (2.3) 3 The degree of faculty supervision between 8 pm and 8 am attracts candidates to this residency program Yes 2.4 (0.9) 21 3.5 (0.6) 16 3.5 (0.9) 23 3.4 (1.2) 17 — Res = 0.06 Cov = 0.01 Inter = 0.02 No 3.3 (0.7) 10 3.6 (1.1) 16 3.6 (0.8) 20 3.9 (0.8) 20 5.0 (0.0) 3 How would you rate your overall educational experience of nighttime call between 8 pm and 8 am ? Yes 3.4 (0.9) 21 3.9 (0.9) 16 3.9 (1.0) 23 3.5 (1.2) 17 — Res = 0.02 Cov = 0.07 ∗ Inter = 0.03 No 4.1 (1.2) 10 3.9 (0.9) 16 4.3 (0.7) 20 4.3 (0.7) 20 4.7 (0.6) 3
Cov, 24-hour/7 days per week/365-day coverage; inter, interaction; res, resident level; SD, standard deviation.
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Comments
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Discussion
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Summary
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Supplementary data
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Appendix
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