As radiologists, we are aware that the complexity of imaging has increased, along with the sophistication of modern medicine and of patient expectations and the demands of the regulatory environment. As a result, we have seen a tremendous increase in the demand for and utilization of imaging. Although this is a boon for radiologists in many ways, it has brought additional pressures with it.
We need to educate our residents to read these highly complex studies, to be clinically productive and academically curious, to prioritize competing, highly compelling demands critical to patient care, and to remain painstakingly careful in the evaluation of images. Although it seems that we hold them to high standards, we hold them to different standards simultaneously, within their role as residents. During the day we expect them to be courteous and respectful of the demands placed on them, and to defer to the attending radiologist in critical decision making. They function as students, as apprentices, and as radiologist extenders. We expect them to model our behavior, and in so doing, learn to become exemplary radiologists. Because resident rotations are usually subspecialty structured and staffed, residents are often held to an academic, subspecialty standard of interpretation and performance.
On call, however, they are expected to make critical decisions about prioritization of their attention and of interpretation alone. Radiology educators believe that this practice is essential for the development of independent practitioners who will be able to make critical decisions under pressure, and thus provide safe, quality care to patients and add value to medical decision making ( ).
Residency programs have a backup system, sometimes a more senior resident or fellow, and always an attending radiologist. However, the backup radiologist may not be expert in the subspecialty area in question. The residents are often more aware than we are of our limitations, and may believe, sometimes correctly ( ), that their interpretation is as good as or better than that of their backup. This belief colors their decisions about when to ask for help.
It is in this environment that the Radiology Resident Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) has changed the length of time required before the residents may take independent call, from 6 to 12 months. It may seem intuitive that decisions of such a critical nature should not be made by trainees, affecting, as they do, the lives of a highly vulnerable population, but in this era of evidence-based medicine, it is essential that we depend not on what seems obvious, but on data driven evidence.
“Discordance rates between preliminary and final radiology reports on cross-sectional imaging studies at a level one trauma center” by Stevens et al, in this issue of Academic Radiology, provides data regarding the discrepancy between resident and attending interpretation of on-call imaging studies. In this work, the authors identified discrepancies and classified them based on their significance. They looked at scan type, area imaged, time of day, and day of the week for studies performed outside of usual working hours. The preliminary interpretations were performed by second and third year residents, with the final read provided by subspecialty attending radiologists. The work also looked at the timeliness and manner in which discrepant results are reported to the emergency department, whether the discrepancy is accurately reported in the final radiology report or in the patient record, and the effect on patient outcome ( ).
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References
1. Ruchman R.B., Jaeger J., Wiggins E.F., Seinfeld S., Thakral V., Bolla S., Wallach S.: Preliminary radiology resident interpretations versus final attending radiologist interpretations and the impact on patient care in a community hospital. AJR Am J Roentgenol 2007; 189: pp. 523-526.
2. Gunderman R.B., Delaney L.R.: Should 12 months of training be required before diagnostic radiology residents take independent call?. J Am Coll Radiol 2007; 4: pp. 590-594.
3. Barnstetter B.F., Morgan M.B., Nesbbit C.E., et. al.: Preliminary reports in the emergency department: is a subspecialist radiologist more accurate than a radiology resident?. Acad Radiol 2007; 14: pp. 201-206.
4. Stevens K.J., Griffiths K.L., Rosenberg J., Mahadevan S., Zatz L.M., Leung A.N.C.: Discordance rates between preliminary and final radiology reports on cross-sectional imaging studies at a level 1 trauma center. Acad Radiol 2008; 15: pp. 1217-1226.
5. Ojutiku O., Harramati L.B., Rakoff S., Sprayregen S.: Radiology residents’ on-call interpretation of chest radiolgraphs for pneumonia. Acad Radiol 2005; 12: pp. 658-664.
6. Cervini P., Bell C.M., Roberts H.C., et. al.: Radiology resident interpretation of on-call CT pulmonary angiograms. Acad Radiol 2008; 15: pp. 556-562.
7. Bansal A.: Twenty-four-hour attending physician coverage and its impact on resident training. J Am Coll Radiol 2005; 2: pp. 642-644.
8. Association of Program Directors in Radiology: PDR response to the RRC, 11/29/06, added to the website 12/8/06. http://apdr.org/documents/pdffiles/ACGME%20comment%2006-1.pdf Accessed June 30, 2008