Saving time, enhancing training with the four o’clock rule

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A debate continues to rage in radiology training programs over the role of residents: Are they an advantage or a detriment in the daily workload of an academic radiology department?

One side of attending radiologists argues that resident assistance permits them to work faster. These radiologists say that while their residents are working on preliminary reports, they can quickly dictate other studies and then rapidly move on to review the resident studies, resulting in a net time savings.

The other side of attendings, meanwhile, make the case that their day runs much more efficiently if they read out the studies themselves---the less resident involvement, the better, these physicians opine.

There is no question that residents must be part of the clinical service to enhance their training. It enables them to acquire knowledge of the various diseases demonstrated by the studies they view during the course of the work day. And while working with the attending physicians at the workstation, they learn the proper approach to interpreting studies, formulating a differential diagnosis, and generating a cogent impression. Their preliminary dictations are reviewed by the attending, who provides constructive criticism. The residents also learn how to consult for referring physicians. For more ambitious residents, a particular may even lead to a research project idea.

Yet it is also true, from the perspective of the attending radiologist, that despite all these putative benefits, residents can be a mixed blessing. Certainly, the attending radiologists enjoy teaching and doing other academic things; otherwise, they would have become community radiologists. Providing mentorship is a defining career element for many. As the volume of clinical work expands, however, academic radiologists often find themselves caught between the imperative of reviewing studies preliminarily and laboriously dictated by residents, and their own responsibility to crunch through the daily workload in a reasonable amount of time.

Indeed, as the hands of the clock inch closer to the end of an arduous, ten-hour day, it becomes difficult for attending physicians even on the other side of the debate to resist the “less-resident-involvement-the-better” attitude.

Enter the four o’clock rule, which we initiated some years ago in the chest section of our radiology department. This rule specifies that residents can preliminarily read all the studies they desire from the morning through the mid-afternoon. After 4 p.m., however, they are no longer permitted to start interpreting any new studies. Instead, all studies are then read by attending radiologists until quitting time, which typically is 5 p.m.

The residents are not necessarily dismissed from service at 4 p.m. They continue to handle a variety of other responsibilities, such as answering calls, entering protocols for studies that evening or the following day, and calling in any critical results for the attending physicians. But if two or more residents are on duty and the afternoon is manageable, it is customary to send one or more residents home early.

The four o’clock rule provides residents with high-quality training for the majority of the work day while also permitting an efficient and timely wrap up at day’s end. It has become locally famous in the department and has received plaudits from both residents and faculty.

Indeed, when it comes to improving efficiency without compromising radiologist training, who can argue with that?

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White CS.  Saving time, enhancing training with the four o’clock rule.  Appl Radiol.  2018;47(12):6-7.

By Charles S. White, MD| December 03, 2018
Categories:  Section

About the Author

Charles S. White, MD

Charles S. White, MD

Dr. White is Professor of Radiology at the University of Maryland School of Medicine, Baltimore, MD. Dr. White is also on the Editorial Advisory Board of Applied Radiology.



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