24/7 revisited

Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

In July 2005, I wrote an editorial entitled "24/7: Do we need it?" ¹ This was well before our Trauma/Emergency Department section was providing this service, although we were covering the evenings until midnight with in-house faculty, as many other institutions are. Roughly a year ago, we added the overnight shift and, very quickly, things became a lot more difficult to manage.

Like many changes, there were both beneficial and detrimental effects for the radiologists, the referring services, the residents, and the radiology department. I thought I would share some of these; I hope to help anyone reading this who is contemplating starting or currently wrestling with this level of coverage.

First, for us, the driving force to start this full-time radiology service was not the clinical referring base. Even the emergency and trauma departments were satisfied, if not always thrilled, with the coverage we already offered. Even though there is abundant evidence that radiology residents (at least beyond the first year of training) did nearly as well as attending radiologists in academic centers in terms of diagnostic accuracy, ^2,3 our risk management group was not comfortable with the existing overnight resident coverage. Apparently, the residents in other departments had not fared as well, so the push to provide in-house 24/7 attending coverage in all appropriate departments was initiated. The emergency department historically had faculty in-house at all times.

Since risk management was behind the push for 24/7 radiology faculty, they were willing to push the hospital administration for the extra dollars to support this activity. After all, the cost of essentially hiring another radiology attending was nothing compared with a multimillion dollar judgment for a plaintiff. This allowed us to sweeten the overnight hours with an extra financial incentive, as well as a smaller incentive for the busy evening coverage that was never so rewarded in the past. The overnight radiologist serves 7 nights and is then off for the following week. Among the section staff, 6 of 7 were reasonably anxious to take the night call. Perhaps you can guess which of us demurred.

The physiologic challenge is real and takes some getting used to, but everyone who has done it has fared well ultimately. There is a definite disruption to life in the real world, but the next week off allows much greater opportunity to get things done academically and in "real life" than is usually possible in typical daytime coverage arrangements.

So what have the upsides been? First, there is better communication between services. Since the attending radiologist is already in-house, many issues that would be otherwise be re-ferred by telephone to the on-call staff can be negotiated more readily at an attending level before other subspecialists are involved. The radiology resident has back-up to whom to refer controversial situations. It is typical for residents on direct patient-care services to invoke the well-known "but my attending wants it" line when certain requests for imaging studies or STAT procedures are resisted by the radiology resident. Now their attending can talk directly to the radiology attending. Strangely, many of these attendings never actually address such matters with the staff radiologist. The residents can resolve difficult cases and have questions answered directly. They get immediate feedback on mistakes or "great calls." The referring physicians feel more comfortable with a faculty-level interpretation and are impressed at the interest level of the department in patient care. Perhaps patient-care management decisions are made more quickly and overall care is improved; that's hard to measure. The attending radiologist can earn greater income and have much more time-off.

So what are the downsides? Schedules are a nightmare to plan with the obligatory weeks off, vacations, meetings, etc. There is very little buffer in the schedule should someone have an emergency or become ill. The residents do not get a chance to make many mistakes and thus to learn in a most effective fashion. Struggling through a tough case and making tough calls is of huge educational benefit. If you are the evening or night attending, you work your butt off.

These are the hours when things are really happening in the hospital; most patients are admitted, are postop, or are actually having management decisions instituted after the day's rounds, conferences, consults, etc. If you cannot work very fast-with confidence-and deal simultaneously with lots of "problems" that arise every few minutes, this is no responsibility for you. Since the section is scattered across 3 blocks of coverage time, it is common to go a month without seeing a colleague in the section. It makes having section meetings difficult and, in general, makes communication very ineffective, despite e-mail. The interpersonal interaction that the section thrives on is strained. There is, in general, a much higher stress factor in our careers. We do not work on the schedule of the rest of the department. Giving conferences, attending Grand Rounds, attending staff meetings, etc. all become problematic. Just having the majority of the section interview a faculty candidate during the day is like pulling teeth.

We have learned to cope with most of these problems and are looking to add staff to increase our coverage buffer. Some of the nonemergency radiology staff is willing to provide support for difficult-to-cover blocks of time when they occasionally arise. We are trying to prepare monthly schedules earlier to prevent last-minute changes as much as possible. Any additional after-hours radiology staffing needs will be provided via teleradiology from home.

As to the question I posed in the 2005 editorial, the answer is yes-we should provide 24/7 coverage in radiology, at least in any institution that handles large numbers of emergency and critically ill patients. Personally, I do not believe academic institutions should shunt their after-hours cases to nighthawk services. I believe it abrogates our responsibility and undermines the added value we give and are recognized to provide in our own practices. Clearly, there are practices for which nighthawk coverage is necessary and certainly of more benefit than no coverage. The days of the 9-to-5 radiologist are gone for most of us. Whenever the nonradiologist faculty on our staff deride our apparently easy life, I remind them that I spend far more and varied hours in the hospital than they do. I also invite them to spend an evening or night with me in the "radiology war room." So far, there haven't been any takers.

REFERENCES

1. Mirvis SE. 24/7: Do we need it? Appl Radiol. 2005;34(7):6.
2. Wysoki MG, Nassar CJ, Koenigsberg RA, et al. Head trauma: CT scan interpretation by radiology residents versus staff radiologists. Radiology. 1998;208:125-128.
3. Carney E, Kempf J, DeCarvalho V, et al. Preliminary interpretations of after-hours CT and sonography by radiology residents versus final interpretations by body imaging radiologists at a level 1 trauma center. AJR Am J Roentgenol. 2003;181:367-373.