Let them have the nights

By Stuart E. Mirvis, MD, FACR
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Dr. Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland School of Medicine, Baltimore, MD.

Hospitals are open 24 hours a day. Patients arrive at all hours and want the same quality of care at all times. This is a realistic expectation. Typically, the most severely ill patients arrive at the hospital, usually through the Emergency Department, at less than convenient times when most attending physicians are gone for the day.

When I was an intern, I thought it was rather peculiar that the least experienced physicians (doctors in diapers) were caring for the sickest patients. In these circumstances you flew by the seat of your wet pants and hoped everyone, including you, survived the night. I was reminded constantly by attending physicians that this approach was the best way to learn how to be a good doctor. That’s one opinion. The point was that at night there were few, if any, really experienced, knowledgeable attending-level physicians around. This is presumably not optimal for patient care.

In recent years, more and more attending physicians or their surrogates have provided in-house 24/7 consultation. This was mainly done in the Emergency Department and Intensive Care Units. Still, most staff attending physicians are “off” after “routine hours,” but provide availability on assigned call. Unfortunately, many training physicians often do not know when to consult the attending or are hesitant to do so.

Today the volume, speed and sophistication of diagnostic imaging have grown enormously. The current expectation is that, in many cases, imaging results are critical in reaching a correct diagnosis and allowing rapid treatment. The demands and reliance on our specialty have never been greater. Still, in most settings, real-time imaging interpretation by attending radiologists does not occur after “routine”hours. Given the pivotal position of diagnostic imaging in patient management decisions, the idea of “we’ll see it in the morning” abrogates radiologists’ most meaningful input to care.

The physical, or at least electronic, presence of attending radiology staff after routine hours must be regarded as crucial. While residents in academic centers can often provide highly accurate interpretations, these preliminary reports are not definitive and should not provide the basis for management decisions. This is particularly true in emergency situations where rapid, accurate interpretation is most vital.

In the last decade, more or less, diagnostic imaging services have grown rapidly using telemedicine to interpret studies at various locations and any distance. Although this service was considered quite novel initially, the approach has steadily gained in popularity, especially after typical daytime working hours. To make up for the “afterhours” quality gap occurring in many hospitals there are now several well-established teleradiology reading services. Apparently, such services generally offer rapid, less-expensive and accurate interpretations and use careful radiologist credentialing and quality monitoring. From everything I‘ve heard and read, these services do a good job.

The next development appears inevitable though. If images can be interpreted quickly and accurately at night, why can’t that happen during the day? CT, MRI, radiography and nuclear medicine are easy pickings. Does the referring physician really need the radiologist or just the interpretation? The attitude of “let them have the nights” opens the door to “they will take the days.” While some major “offhours” teleradiology services have steered away from “raiding” departments in such a fashion, there are others that would gladly supply such coverage with subspecialty support to boot.1-4

It is vital that radiologists staffing a department implement a plan such that they are the only radiologists the referring clinicians need to know. They should be the only group consulted on diagnostic imaging in the hospital. To maintain this position, groups will have to stretch and provide 24/7 coverage. Larger groups will have less trouble handling this challenge, but smaller groups will need to create after-hours coverage consortiums where coverage is shared among groups. To some extent all of the involved radiologists should be recognized as part of the local department to diminish the perception of “outside” or “nighthawk” support. In my view, academic centers also have an obligation to offer 24/7 coverage, not because of threats from the outside, but to provide the highest quality interpretations available, regardless of when a patient arrives. Providing this service by teleradiology, while perhaps not as valuable as actually being present in the hospital, enhances the local group’s value. For many staff radiologists the use of teleradiology would mitigate the difficulty and stress of in-house coverage. In my view, service during non-daytime hours should be appropriately compensated by extra income, time off or both.

We are not living in the era of the 9-to-5 hospital-based radiologist. We obviously need to offer care to the patients in our own backyards at all times. While there are many ways to become indispensable in a radiology practice, being available when care decisions are being made is certainly one of major importance.

REFERENCES

  1. Nighthawks, dayhawks, and the demise of the American radiologist. Available online: http://www.kevinmd.com/blog/2009/03/nighthawks-dayhawks-and-demise-of.html.Accessed August 12, 2010.
  2. Bradley WG. Off-site teleradiology: The Pros. Radiology. 2008;248:337-341.
  3. Thrall JH. Teleradiology. Part 2. History and clinical applications. Radiology. 2007;243:613-617.
  4. Boland GWL. Teleradiology coming of age: Winners and Losers. AJR Am J Roentgenol. 2008;190:1161-1162.
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Let them have the nights.  Appl Radiol. 

September 16, 2010



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