Rationale and Objectives
The purpose of this study is to quantify the clinical impact of resident-attending discrepancies at a tertiary referral academic radiology residency program by assessing rates of intervention, discrepancy confirmation, recall rate, and management change rate; furthermore, a discrepancy categorization system will be assessed.
Materials and Methods
Retrospective review of the records was performed for n = 1482 discrepancies that occurred in the 17-month study period to assess the clinical impact of discrepancies. Discrepancies were grouped according to a previously published classification system. Management changes were recorded and grouped by severity. The recall rate was estimated for discharged patients. Any confirmatory testing was reviewed to evaluate the accuracy of the discrepant report. Categorical variables were compared to the chi-square test.
Results
The 1482 discrepancies led to management change in 661 cases (44.6%). The most common management change was follow-up imaging. Procedural interventions including surgery occurred in 50 cases (3.3%). The recall rate was 2.6%. Management changes were more severe with computed tomography examinations, inpatients, and when the discrepancy was in the chest and abdomen subspecialty. Also, management changes correlated with the discrepancy category assigned by the attending at the time of review.
Conclusions
Resident-attending discrepancies do cause management changes in 44.6% of discrepancies (0.62% overall); the most frequent change is follow-up imaging. The discrepancy categorization assigned by the attending correlated with the severity of management change.
Rationale and Objectives
A fundamental concept in radiology residency training is the development of independence in a paradigm of graded responsibility. In the past, residents obtained this experience working nights for the practice in which their residency was embedded. Although this model persists in many departments, there is an increasing drive to a 24-hour coverage model with an attending radiologist, even subspecialty radiologist, providing direct resident supervision and final signing throughout the night. This model poses a challenge to fostering independence in residency, particularly in the early years of training.
One of the strongest arguments for the 24-hour attending coverage is the need to avoid resident-attending discrepancies that lead to significant changes in management, particularly for discharged or critically ill patients. Although this justification is inherently reasonable, it is easy to overemphasize its importance when the true impact of discrepancies is not well defined. Previous studies have determined what the discrepancy rates are in several resident practice environments . Others have shown that discrepancy rates are correlated with duration of shift and vary with different imaging study types .
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Materials and Methods
Case Selection
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Discrepancy Analysis
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TABLE 1
Description and Total Numbers of Clinical Management Changes Categorized and Grouped by Severity
Management Change Severity Class Number of Cases Therapeutic intervention 3 81 Medication change 102 Diagnostic intervention 31 Follow-up imaging 2 282 Discharge delay/admission/change in level of care 6 Consult or clinic visit 25 Stopped workup 1 9 Physical examination 21 Laboratory examination 17 Called patient or doctor 87 No change in management 821 Total 1482
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Statistical Methods
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Results
Case Selection
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Discrepancy Classification
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TABLE 2
Modality and Study Types of the Discrepant Studies
Modality Study Type_n_ Total CT CT abdomen pelvis 491 1013 (68.4%) CT chest 211 CT head 146 CT angiogram head/neck 29 CT spine 57 CT face/sinuses 33 CT MSK 8 Consult 38 CR CXR 264 469 (31.6%) CR MSK 191 CR abdomen 14 Total 1482
CR, computed radiography; CT, computed tomography; CXR, chest x-ray; MSK, musculoskeletal.
TABLE 3
(a) Ten Most Frequent Organs with Discrepancies; (b) Ten Most Frequent Discrepant Diagnoses
(a) Organ Number of Discrepancies Lung 271 Brain 120 Colon 84 Small bowel 74 Kidney 51 Pulmonary artery 43 Rib 36 Cervical spine 34 Peritoneum 31 Thoracic spine 29
(b) Diagnosis Number of Discrepancies Fracture 130 Pneumonia 104 Pulmonary nodule 54 Compression fracture 37 Pulmonary embolism 33 Brain infarct 28 Colitis 25 Obstruction 23 Aneurysm 18 Subdural hematoma 18
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Management Changes
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TABLE 4
Discrepancy Frequencies Grouped by Management Change Group and Subgrouped by Modality, Type of Error, Discrepancy Class Location and Severity, Attending Subspecialty, and Overread Subspecialty
(a) Management Change Group Modality Type of Error Discrepancy Class—Location Discrepancy Class—Severity CR CT Observation Interpretation Discharged Admitted In ED a (Critical) b (Time Dependent) c (Non-time Dependent) 1 (Mild) 49 87 95 41 94 32 10 2 51 83 2 (Moderate) 115 196 224 87 60 193 58 5 175 131 3 (Severe) 54 160 150 64 35 139 40 5 158 51 Total 218 443 469 192 189 364 108 12 384 265P -value .013 .848 <.001 <.001
(b) Management Change Group Attending Subspecialty Overread Subspecialty Abdo Chest MSK Neuro Abdo Chest MSK Neuro 1 (Mild) 58 45 12 21 55 25 30 26 2 (Moderate) 110 122 9 70 78 114 43 76 3 (Severe) 76 101 5 32 81 74 24 35 Total 244 268 26 123 214 213 97 137P -value .002 <.001
Abdo, abdomen; CR, computed radiography; CT, computed tomography; ED, emergency department; MSK, musculoskeletal.
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Review Latency
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Recall Rate
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Attending Performance
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Discussion
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Conclusions
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