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Hot Topic: 24 Hour Attending Coverage
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The views that the author expresses in this article are strictly their own and should not be attributed to the American College of Radiology.
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Reprinted with permission from JACR
Volume 2, Issue 7, Pages 642-644 (July 2005)
Twenty-Four-Hour Attending Physician Coverage and Its Impact on Resident
Training
Anu Bansal, MD
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...is committed to serving the community. We are dedicated to enhancing patient
care, teaching and research, and to taking a leadership role as an integrated
health care system.
The above is excerpted from the mission statement of the hospital that sponsors
my residency program. Such a statement is likely to be found similarly worded,
if not verbatim, in many others around the country.
Although different instruments have occasionally generated contradictory results
(i.e., Press Ganey Associates), at least one major survey (NRC+Picker Group) has
reported that smaller community hospitals generally achieve greater patient
satisfaction than larger teaching institutions [1]. The most common explanation
offered for this finding is that community hospitals focus exclusively on the
mission of patient care, without having to expend additional resources on
teaching and research, and are therefore able to accomplish this singular goal
more effectively.
These data seem to put the mission of patient care somewhat at odds with those
of teaching and research. Most physicians are familiar with the ill-conceived
but commonly (at least during residency) proffered adage "Watch one, do one,
teach one." Would anyone realistically contend that an intern placing a central
line after having "watched one," even if adequately supervised, is really the
best a hospital can offer in terms of patient care? Rephrasing the question in a
radiologic context, how many people think that a first-year resident with 7
months of training should be responsible for performing an ultrasound
examination with umbilical cord Doppler flow studies on a 30-week twin gestation
on call? (I actually had to do this; the patient went to the operating room for
a stat cesarean section.)
Despite this apparent incongruity, it is within the nature of an academic
institution to try to incorporate teaching and research with patient care; on
the surface, most seem to do so rather seamlessly. However, there is a constant
(and appropriate) emphasis on improving patient care, and sometimes, the easiest
way to accomplish this is at the expense of either research or teaching.
Nationwide, clinical medicine has become increasingly reliant on diagnostic
imaging, leading to a call for 24-hour in-house radiology attending physician
coverage from other clinicians [2]. For example, in our hospital, there has been
a strong desire on the part of both the radiology and hospital administrations,
as well as among cardiothoracic and trauma surgery attending staff members, for
24-hour in-house attending physician coverage of the emergency department. The
remainder of this piece examines the arguments in favor of and opposed to
24-hour attending coverage, as well as the early impact 24-hour coverage has had
on resident training at our institution.
Pros
The single best argument in favor of the institution of 24-hour attending
physician coverage is the improvement in patient care. However, to fully
appreciate the degree of improvement, it is necessary to first examine the
amount of error typically encountered with the more common scenario of overnight
resident coverage. A number of studies have tried to assess the percentage of
errors made by radiology trainees when working alone. For example, a large study
examining trainee and staff member interpretations of pediatric emergency x-rays
demonstrated 80 errors in 23,273 dictations, a 0.3% error rate [3]. Another
study examined trainee error rates in the interpretation of body computed
tomography and ultrasound examinations and found a 3.2% minor and 0.5% major
error rate [4]. Finally, a study looking at all types of emergent
neuroradiologic imaging demonstrated a 0.9% trainee error rate, with a 0.08%
rate of errors with the potential for serious clinical complications [5]. Having
an attending radiologist on staff with an on-call resident would have
theoretically eradicated most or all of these errors, a small subset of which
had the potential to affect patients' clinical outcomes.
An additional advantage of providing 24-hour attending physician coverage is the
improved rapport a radiology department achieves with other departments, as well
as within the infrastructure of the hospital itself. In our hospital, emergency
physicians, as well as cardiothoracic, trauma, and general surgical staff
members, appreciate being able to get an "attending physician read" on a study
before sending or taking a patient to the operating room. In addition, they have
the added benefit of being able to discuss a case in person with an attending
physician, just as they might do during "normal" working hours.
What about the impact on residents? At a time when the on-call workload is
increasing exponentially [6], the addition of overnight radiology staff members
provides a significant cushion for a resident who would otherwise be covering a
busy emergency room and inpatient service alone. In addition, overnight staff
members obviate the scary situations that junior residents often find themselves
in (remember my patient with 30-week-old twins?). Finally, there is the
potential for improved teaching throughout the night instead of during a readout
session the next morning, when residents are tired and probably least receptive
to learning.
Cons
The most common argument against providing 24-hour attending physician coverage
in a teaching institution is the potential impact it would have on residency
training. Many argue that residents have been well served by the traditional
"trial by fire" method of teaching and that it is hard to acquire confidence as
a trainee without this. If you have never had to convince a senior
cardiothoracic surgeon that a patient has a type A aortic dissection extending
into an aberrant right subclavian artery and that the findings are adequately
seen on a computed tomographic scan done to evaluate for a pulmonary embolism
(this call experience occurred during my second year), have you really been
adequately trained as a radiologist?
Additional disadvantages include the considerable added expense of hiring
dedicated overnight radiology staff members, as well as the potential discontent
of daytime staff members, who could potentially be made to cover overnight
shifts [7].
Is there a way to compromise?
In July of this year, our emergency radiology department initiated 24-hour
in-house attending physician coverage by hiring three new dedicated "nighthawk"
attending radiologists. These attending radiologists work in a distinct (but
nearby) location from the residents and are responsible for a number of
teleradiology studies in addition to those from our emergency room. They have
multiple readout sessions with residents at approximately 2-hour intervals and
cover from 11 p.m. until 7:30 a.m.
An informal survey of residents in my program demonstrated several ways in which
24-hour attending physician coverage has had a positive impact on resident
training. Two-thirds of respondents felt that the overall experience of taking
call in the emergency room was improved, primarily because of shorter work hours
secondary to the absence of a prolonged morning readout session. Slightly more
than half of the residents also felt that call was now a better teaching
experience, often because of impromptu teaching occurring during slow periods
overnight. About half of the residents felt that the level of patient care had
improved significantly and that they felt more comfortable when taking call.
However, it is useful to note that the residents who felt this way were
primarily junior (physician graduate years 2 and 3) trainees.
Despite these numerous advantages, almost all residents surveyed in my program
stated that they felt a moderate to severe loss of independence with overnight
attending physician coverage, partly because of the attitude of clinical staff
members and their desire for "final reads." Of course, if a final read is to be
made readily available, it does make sense on the part of clinicians,
particularly those in the emergency department who are especially concerned with
patient flow, to acquire this final read before rendering definitive therapy or
disposition.
How can this be resolved? Or perhaps a better question would be, is this an
issue that needs to be resolved? It is probably impossible to provide residents
with the same degree of independence once 24-hour in-house attending physician
coverage is instituted. However, by giving up some degree of independence, are
residents really losing that important a part of their training? After all, it
is being traded for an improved overall educational experience, decreased
on-call hours, and decreased fear and uncertainty while on call. I know I would
not wish some of the call experiences I have had on anyone (although I do fondly
recall the emergency room attending physician's expression when I insisted that
a patient with a prior appendectomy had recurrent appendicitis in my first year;
I was right, by the way). Is it possible that the trial-by-fire method of
learning is just another form of hierarchical hazing that is so prevalent in
medical training? If it truly cannot be dispensed with, there are other
opportunities during training to work independently, moonlighting being a
readily available option. Another easy method (depending on how reports are
transcribed) is to make residents predictate cases during the day in the reading
rooms with prespecified readout intervals.
The improvement in patient care, however incremental, is measurable, and
teaching institutions still have a primary obligation to provide the best
possible patient care. The short-term experience at our institution demonstrates
that teaching hospitals that choose to provide 24-hour attending coverage likely
will find that they have improved patient care at the expense of a small but
probably inconsequential sacrifice in resident independence.
References
- California Hospital Experience Survey. what patients think of California
hospitals. Available at:
http://www.chcf.org/documents/hospitals/CAHospitalExpSurvey04TechSum.pdf
- Velmahos GC, Fili C, Vassiliu P, et al.. Around-the-clock attending radiology
coverage is essential to avoid mistakes in the care of trauma patients. Am Surg.
2001;67:1175-1177.
- Halsted MJ, Kumar H, Paquin JJ, et al.. Diagnostic errors by radiology
residents in interpreting pediatric radiographs in an emergency setting. Pediatr
Radiol. 2004;34:331-336.
- 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. Am J
Roentgenol. 2003;181:367-373.
- Lal NR, Murray UM, Eldevik OP, et al.. Clinical consequences of
misinterpretations of neuroradiologic CT scans by on-call radiology residents.
Am J Neuroradiol. 2000;21:124-129.
- Carroll TJ. Trends in on-call workload in an academic medical center
radiology department 1998-2002. Acad Radiol. 2003;10:1312-1320.
- Steele RD, Kerr HH. 24-hour radiology. Am J Roentgenol. 1997;169:953-954.
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