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The Effect of International Teleradiology Attending Radiologist
Coverage on Radiology Residents’ Perceptions of Night Call
Sandor A. Joffe, MDa, Jarett S. Burak, MDa, Marlene Rackson, MDa, Devon A. Klein, MDb, Marshall M. Joffe, MD, MPH, PhDc
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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 3, Issue 11, Pages 872-878 (November 2006)
The Effect of International Teleradiology Attending Radiologist
Coverage on Radiology Residents’ Perceptions of Night Call
Joffe SA, Burak JS, Rackson M, Klein DA, Joffe MM
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Purpose: The purpose of this study was to determine the effects of
international teleradiology attending radiologist coverage (ITARC) of
emergency examinations on radiology residents’ perceptions of night
call.
Methods: A survey was administered at 2 different radiology
residency programs that have attending radiologists who cover the night
shift via teleradiology from Israel 5 nights per week. The survey
consisted of 12 questions concerning residents’ education and anxiety
during on-call shifts and the effects of ITARC on these aspects of
residency training. The questions were answered on a scale ranging from
1 to 5, with 3 being neutral.
Results: The radiology residents felt that
ITARC improved the on-call learning experience (score 3.7; 1 much worse,
5 much improved). The residents felt neutral about the statements
"Review of cases with the attending radiologist over the telephone is
comparable educationally to having the attending radiologist in person
at the workstation" (score 3.0) and "Having an attending radiologist
easily available diminishes the need for me to commit to a diagnosis on
my own and is therefore detrimental to my education" (score 2.9; 1
strongly disagree, 5 strongly agree). The residents’ stress levels on
call were high without ITARC (score 1.8; 1 very high, 5 very low)
and moderate with ITARC (score 2.7). The residents’ anxiety levels
before a night on call were moderate without ITARC (score 2.9; 1
very high, 5 very low) and low with ITARC (score 3.7).
Conclusions: Radiology residents felt that ITARC improved their educational
experience. International teleradiology attending radiologist coverage
also decreased radiology residents’ stress and anxiety related to
on-call shifts.
Key Words: Teleradiology, nighthawk, off-hours radiology
coverage, resident education
J Am Coll Radiol 2006;3:872-878. Copyright© 2006 American College of Radiology
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INTRODUCTION
Over the past 20 years, teleradiology has become a common and effective method of
providing radiology night coverage at hospitals throughout the United
States [1]. The volume of radiologic studies performed at night in
emergency departments has rapidly increased, particularly more
complicated studies such as abdominal computed tomography (CT) and CT
pulmonary angiography [2], and there has been a demand for the
contemporaneous interpretation of these examinations for the sake of
patient care. In 2001, the ACR [3] issued a resolution that "all
radiologic studies performed on emergency department patients should be
promptly interpreted by radiologists." Outsourcing night coverage via
teleradiology can improve the efficiency of coverage, with 1 radiologist
covering multiple hospitals, and can improve work efficiency during the
day by allowing staff radiologists to get adequate rest at night [4,5].
International teleradiology, with the transmission of images abroad, has
been used for more than a decade [6].
International teleradiology has
been used to cover routine, nonemergent examinations [7,8]. One major
benefit of international teleradiology attending radiologist coverage
(ITARC) is the time difference that permits a teleradiologist to be
awake and alert by working normal daytime hours while covering the night
shift in the United States [9,10]. International teleradiology attending
radiologist coverage requires the security of a virtual private network
and redundancy in Internet connections to eliminate downtime [9]. The
rapid transmission of images is necessary to permit contemporaneous
interpretations. An international teleradiologist should be licensed in
all states and credentialed in all hospitals in which examinations are
performed and preferably should be certified by the American Board of
Radiology [11].
The majority of hospitals using teleradiology for night
coverage are not academic hospitals; however, teleradiology, including
ITARC, is also being used in academic hospitals with radiology residency
training programs [10,12]. Although most interpretations by residents
are accurate, interpretations by attending radiologists are more likely
to be accurate [13]. Minor discrepancies between residents’ and
attending radiologists’ interpretations of body CT scans have been
demonstrated in 5.4% to 26.6% of cases, with major discrepancies in 1.0%
to 2.3% [14,15]. In trauma CT cases, Velmahos et al [16] reported minor
discrepancies in 11% of cases and major discrepancies in 5% and
concluded that attending radiologist coverage is essential to avoid
mistakes in these patients. Although Carney et al [15] found that these
discrepancies did not adversely affect patient care, contemporaneous
interpretations of emergency examinations by attending radiologists are
preferable. On the other hand, the experience gained during on-call
shifts by radiology residents is important in their assumption of
clinical responsibility and their development of critical decision
making [15].
At our institutions, ITARC interfaces with radiology
residency training. The purpose of this study was to determine the
effects of ITARC of emergency examinations on radiology residency
training.
METHODS
A survey was administered in March 2004 at 2 different
radiology residency programs that have the same attending radiologist
providing coverage of the night shift via teleradiology from Israel. The
night-shift coverage was provided 5 nights per week from midnight until
8 AM for both Beth Israel Medical Center (BIMC) and St. Luke’s-
Roosevelt Hospital Center (SLR). The attending radiologist had
subspecialty experience in abdominal imaging. The survey was
administered by the program directors of the residency programs.
Both medical centers were digital departments, equipped with picture
archiving and communication systems. The attending radiologist had a
picture archiving and communication system station and Web browser
software that was connected to both BIMC and SLR via a virtual private
network. The virtual private network granted him access to all
hospital-based imaging and computer systems, including the picture
archiving and communication system, Talk Technology voice recognition
software for dictation (Talk Technology, Brooklyn, NY), and the IDX
radiology information system (IDX Systems Corporation, Burlington, Vt).
The attending radiologist had access to all emergency studies
interpreted by residents and usually obtained the images 15 to 30
minutes after they were available to residents. The attending
radiologist was accessible by telephone with a local telephone number
using the voiceover- Internet protocol (VoIP). The attending radiologist
typically interpreted all emergency body CT scans and ultrasound
examinations from BIMC and was available to consult on other
examinations, such as CT scans of the head and plain radiographs, at the
request of an on-call radiology resident. The attending radiologist did
not interpret any of the examinations from SLR unless specifically
requested to by an on-call resident. For the most part, the examinations
from both institutions were interpreted independently by radiology
residents before the attending radiologist interpreted the studies.
Occasionally, radiology residents contacted the attending radiologist
for advice before issuing reports. Differences in the attending and
resident radiologists’ interpretations were usually discussed by
telephone at the time of the attending radiologist’s interpretation. The
resident and attending radiologists were able to discuss cases directly
in real time by referencing specific image numbers on a given study. In
addition, the attending radiologist’s final reports were available to
the radiology residents immediately after dictation.
Twenty first-year
and second-year radiology residents participated in the survey, all 11
from BIMC and 9 of 12 from SLR. The residents were unaware of the
purpose of the survey until after it was administered. The survey
consisted of 12 questions concerning residents’ education and anxiety
during on-call shifts and the effects of ITARC on these aspects of
residency training. The questions were answered on a scale ranging from
1 to 5, with 5 being the most positive choice.
For each question, we
calculated descriptive statistics, including means and standard
deviations, and further calculated these statistics by year of residency
and location of residency. When questions were asked separately about
experiences with and without teleradiology coverage, we calculated
differences in responses between the questions. We used the sign test
(using exact binomial 2-sided P values, which are appropriate even with
small numbers of subjects and data that are not normally distributed)
to test whether the median responses were the same with and
without teleradiology coverage. We also used the sign test to test
whether median responses were more likely to be favorable ( 3) than
unfavorable ( 3). We used Stata version 9.1 (StataCorp LP, College
Station, Tex) for all calculations.
Table 1. Effects of ITARC on residents’ anxiety and stress levels
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Total |
P Value |
First-Year Residents |
Second-Year Residents |
BIMC |
SLR |
| What was your level of anxiety prior to a night shift during your first week of night float? |
| Without ITARC |
1.5 (0.6) |
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1.5 |
1.5 |
1.5 |
1.4 |
| With ITARC |
2.8 (0.9) |
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2.5 |
N/Aa |
2.6 |
3.1 |
| Difference |
1.3 (1.0) |
.0005 |
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| What is your level of anxiety now prior to starting a night of night float? |
| Without ITARC |
2.9 (0.8) |
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2.5 |
3.5 |
3.1 |
2.7 |
| With ITARC |
3.7 (0.8) |
|
3.4 |
4.1 |
3.8 |
3.5 |
| Difference |
0.8 (0.6) |
.0002 |
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| What is your stress level during night float? |
| Without ITARC |
1.8 (0.7) |
|
1.6 |
2.1 |
1.9 |
1.8 |
| With ITARC |
2.7 (0.8) |
|
2.6 |
2.9 |
2.8 |
2.6 |
| Difference |
0.9 |
.0001 |
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Note: 1 very high, 2 high, 3 moderate, 4 low, 5 very low. Standard deviations are in parentheses. BIMC Beth Israel
Medical Center; ITARC international teleradiology attending radiologist coverage; N/A not applicable; SLR St. Luke’s-Roosevelt
Hospital Center.
aNote that ITARC began 6 months after the second-year residents began night float, and this question therefore did not apply to the
second-year residents.
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RESULTS
Resident Anxiety and Stress
International teleradiology attending radiologist coverage reduced
residents’ anxiety during their first week of night float, with
first-year residents demonstrating a reduction from a score of 1.5 (high
to very high) to 2.8 (moderate) (P .0005 for testing whether more
positive than negative or vice versa; Table 1). Note that ITARC began 6
months after the second-year residents began night float, and therefore,
evaluation of the effects of ITARC on their first week of night float
was not possible.
International teleradiology attending radiologist
coverage also reduced radiology residents’ anxiety before starting
shifts of night float at the time of the survey, 3 months after the
first-year residents began doing nightfloat shifts and over 1 year after
the second year residents began doing night-float shifts. There was an
overall decrease in anxiety from a score of 2.9 (moderate) to 3.7 (low)
(P .0002), with reductions in first-year residents’ anxiety from 2.5
(moderate to high) to 3.4 (low to moderate) and in second-year
residents’ anxiety from 3.5 (low to moderate) to 4.1 (low). Note that
the anxiety level for second-year residents was lower than for
first-year residents, but ITARC decreased anxiety in both groups.
International teleradiology attending radiologist coverage reduced
residents’ stress levels during night float, with overall reductions
from 1.8 (high) to 2.7 (moderate) (P .0001) and reductions in
first-year residents’ stress levels from 1.6 (high to very high) to 2.6
(moderate to high) and in second-year residents’ stress levels from 2.1
(high) to 2.9 (moderate). Although second-year residents experienced
lower stress levels than first-year residents, ITARC still reduced
stress in second-year residents. The residents felt, with a score of 4.3
(agree; P .0001), that the presence of an experienced radiologist to
help with difficult cases contributed to decreased stress levels (Table
2). Overall, the residents felt neutral, with a score of 3.1 (neutral; P
.3), that the presence of an attending radiologist decreased stress by
reducing residents’ workloads, but there was a discrepancy at different
hospitals, with residents at BIMC agreeing with this statement (score
3.9, P .004) and residents at SLR disagreeing (score 2.2, P .22).
Technical Aspects of ITARC
The residents felt neutral about the
statement that reviewing cases with an attending radiologist over the
telephone was comparable to reviewing cases with an attending
radiologist present, with a score of 3.0 (neutral; P 1.0), with
residents at BIMC feeling more positive (score 3.5, neutral to agree)
and residents at SLR feeling more negative (score 2.3, disagree).
The residents at both training programs felt that meeting an attending
radiologist in person and developing a relationship with the attending
radiologist is important, with a score of 3.7 (agree; P .01). In
addition, the residents found the use of the VoIP telephone to be a
reliable method of communication with the attending radiologist, with a
score of 4.4 (agree to strongly agree; P .0001).
Table 2. Effects of ITARC on residents’ education and technical aspects of ITARC
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Total |
P Value |
First-Year Residents |
Second-Year Residents |
BIMC |
SLR |
| Attending physician teleradiology coverage decreases my stress level on-call |
| Because I know that there is an experienced radiologist to help me with difficult cases. |
4.3 (0.7) |
<.0001 |
4.3 |
4.1 |
4.3 |
4.2 |
| Because the attending interprets some of the examinations without me when I am overwhelmed with a large volume of cases. |
3.1 (1.2) |
.3 |
3.0 |
3.4 |
3.9 |
2.2 |
| Review of cases with the attending radiologist over the telephone is comparable educationally to having the attending radiologist in person at the workstation. |
3.0 (1.1) |
1.0 |
2.9 |
3.0 |
3.5 |
2.3 |
| Meeting the attending radiologist in person and developing a relationship is an important element of ITARC. |
3.7 (0.9) |
.01 |
3.6 |
3.8 |
3.7 |
3.6 |
| The telephone connection to the attending radiologist is clear and reliable. |
4.4 (0.6) |
<.0001 |
4.2 |
4.8 |
4.5 |
4.3 |
| Having an attending radiologist easily available diminishes the need for me to commit to a diagnosis on my own and is therefore detrimental to my education. |
2.9 (1.2) |
1.0 |
2.8 |
3.0 |
2.9 |
N/Aa |
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1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. Standard deviations are in parentheses. Abbreviations
as in Table 1.
aNote that the this question was inadvertently omitted from the survey at SLR and was therefore part of the survey only at BIMC. |
Educational Effects of ITARC
The residents at BIMC felt indifferent, with a score of 2.9
(neutral; P 1.0), that the availability of an attending radiologist
was detrimental to their education by diminishing their need to commit
to diagnoses on their own. Note that this question was inadvertently
omitted from the survey at SLR and was therefore part of the survey only
at BIMC.
The residents felt that ITARC improved their on-call learning
experience, with a score of 3.7 (improved; P .004; Table 3). The
residents found the learning experience on night float slightly better
than other rotations, with a score of 3.6 (no change to improved; P
.12) without ITARC and a score of 3.9 (improved; P .001) with ITARC.
Contemporaneous review of cases with the attending radiologist over the
telephone was better for residents’ education than residents’ reviewing
final reports the fol- lowing night, with a score of 4.0 (improved; P
.04), and was not significantly different from review of cases with an
attending radiologist in person in the morning, with a score of 3.2 (no
change; P .45).
Table 3. Educational effects of ITARC
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Total |
P Value |
First-Year Residents |
Second-Year Residents |
BIMC |
SLR |
| How does attending physician teleradiology coverage affect the on-call learning experience? |
3.7 (0.8) |
0.004 |
3.8 |
3.7 |
3.6 |
4.0 |
| Compared to other rotations, what is the quality of your learning experience during night float? |
| Without ITARC |
3.6 (1.1) |
0.12 |
3.4 |
3.9 |
4.1 |
2.9 |
| With ITARC |
3.9 (0.8) |
0.001 |
3.9 |
3.9 |
4.1 |
3.7 |
| Difference |
0.3 (0.9) |
0.29 |
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| Educational value of reviewing cases with the attending radiologist over the telephone |
| Compared to reviewing the final reports the following night (BIMC only) |
4.0 (1.0) |
0.04 |
3.7 |
4.4 |
4.0 |
N/A |
| Compared to reviewing the studies with an attending radiologist in the morning (SLR only) |
3.2 (1.1) |
0.45 |
3.5 |
2.7 |
N/A |
3.2 |
1 = much worse, 2 = worse, 3 = no change, 4 = improved, 5 = much improved. Standard deviations are in parentheses.
Abbreviations as in Table 1.
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DISCUSSION
This study examined the effect of ITARC on
the training of radiology residents. The survey was distributed to the
first-year and second-year radiology residents at 2 training programs in
New York City. These classes of residents were selected because they
were the ones who regularly covered the night-float rotations and
therefore the ones who interacted directly with the attending
teleradiologist. Note that all the residents who participated in the
survey had the opportunity to work with and without ITARC, because the
attending teleradiologist worked with the residents 5 nights per week
and the residents worked alone on the other 2 nights. Although the
survey was prepared by the attending teleradiologist, it was
administered by the program directors without notifying the residents
that the attending teleradiologist was involved in the survey.
The first
aspect of the survey concerned residents’ anxiety and stress. Anxiety
was considered to be apprehension before an on-call shift, whereas
stress was considered to be a state of worry or mental tension during an
on-call shift. International teleradiology attending radiologist
coverage reduced the radiology residents’ anxiety during their first
week of night float and after multiple shifts of night float. Although
anxiety levels were lower in residents with more experience, including
first-year residents with 3 months of experience and second-year
residents, all these groups demonstrated reductions in anxiety
attributable to ITARC. In addition, stress levels, although higher in
first-year residents than in second-year residents, were reduced in both
classes by the presence of ITARC. These reductions in anxiety and stress
levels were statistically significant.
In examining the reasons behind
these reductions in stress with ITARC, the residents felt strongly that
the presence of an experienced radiologist to help with difficult cases
was a major reason for the decreased stress. Overall, the residents felt
neutral that the presence of an attending radiologist decreased stress
by reducing their workloads. However, at SLR, the radiology residents
consulted the attending radiologist only for difficult cases, and the
attending radiologist did not routinely interpret the cases from SLR and
therefore did not typically reduce those residents’ workloads. At BIMC,
where the attending radiologist routinely interpreted all of the
emergent body CT cases, sometimes before the residents had the
opportunity to interpret the cases, the residents did find that the
reduction of their workloads by the attending radiologist reduced their
stress levels at times of a high volume of cases.
The other major
component of the survey concerned the effect of ITARC on residents’
education. Across the board, the residents felt that ITARC improved
their oncall learning experience, and this finding was statistically
significant. This positive opinion applied to both first- year and
second-year residents and to both radiology residency training programs.
The residents also felt that the learning experience on night float was
slightly better than on other rotations and was slightly better with
ITARC than without ITARC, although this finding was not statistically
significant.
The residents at BIMC felt strongly that the
contemporaneous review of cases with the attending radiologist over the
telephone was clearly preferable to residents’ reviewing final reports
on their own the following night. The residents at SLR demonstrated a
slight preference for contemporaneous review with an attending
radiologist by telephone over the review of cases in the morning with an
attending radiologist in person. The residents felt neutral about the
statement that reviewing cases with the attending radiologist over the
telephone was comparable with reviewing cases with an attending
radiologist present. This implies that the in-person review of cases is
preferable but that review by telephone is an adequate method. Note that
the BIMC residents felt more positive about this statement than the SLR
residents. This difference may be due to the BIMC residents’ comparing
telephone review with the review of reports on their own, although this
was technically not part of the survey question. Although the SLR
residents felt that the in-person review of cases was better than
telephone review, the fact that they found contemporaneous review by
telephone at least equal to later review in person implies that they had
a preference for contemporaneous review, as would be expected
intuitively. Therefore, the presence of an attending radiologist with
whom residents can discuss cases contemporaneously, whether by telephone
or in person, improves the educational experience of radiology
residents.
One potential concern about an attending radiologist’s
presence during on-call shifts is the perceived detrimental effect of
the diminished need for residents to commit to diagnoses on their own.
The survey demonstrated that the residents felt neutral that the
availability of the attending radiologist would have a detrimental
effect on their education. At our institutions, the attending
radiologist usually allows radiology residents to interpret examinations
first on their own. Even when radiology residents, before issuing
preliminary reports, call the attending radiologist for advice on
interpreting cases, the attending radiologist usually asks the residents
for their opinions before offering advice. Therefore, if an attending
radiologist is careful to permit radiology residents to act
independently and accept responsibility for their interpretations to the
extent possible without significantly affecting patient care, there will
not be a significant detrimental effect on residents’ education and
decision making.
The radiology residents at both training programs felt
that meeting attending radiologists in person and developing
relationships with them is important. At our institution, the attending
teleradiologist typically comes to New York twice a year to work for a
few days at the hospitals. He usually gives a few conferences to the
residents from all the affiliated training programs. In particular, one
of these visits is during the first 6 months of residency training, so
that the attending radiologist can meet the first-year residents before
they start the nightfloat rotation.
The residents found the use of the
VoIP telephone to be a satisfactory method of communication with the
attending radiologist. The VoIP telephone allows the attending
radiologist to have a local New York telephone number while working from
abroad. In addition, many VoIP setups have fixed monthly fees,
independent of the number of telephone calls made or minutes used. This
fixed fee removes the potential disincentive of cost from communication
between the attending teleradiologist and health care workers, including
residents, at hospitals. A VoIP telephone therefore allows an attending
teleradiologist and radiology residents to have easy and unlimited
communication that can enhance residents’ education.
A pitfall of this
survey was the small number of residents surveyed. However, because
ITARC is a relatively new phenomenon, only the first-year and
second-year residents had an opportunity to work significantly with the
attending teleradiologist. In addition, 3 of 6 secondyear residents at
SLR were not available at the time of the survey and therefore did not
participate. Despite the small numbers, the effects of ITARC were in
many cases sufficiently large to be statistically significant and not
plausibly due to random variability.
Another limitation of this study is
that its results may not apply to ITARC at other institutions. The
attending teleradiologist involved in this survey has a particular
interest in teaching residents. The attending radiologist and the
residents developed relationships, and the attending radiologist
provided feedback to the residents on a regular basis while allowing
them independence in formulating their own interpretations of
examinations. These conditions may need to be met for ITARC to have
similar results at other academic institutions.
CONCLUSIONS
Attending
radiologist night coverage is becoming more common, particularly with
ITARC. The obvious benefits include improved accuracy of readings after
hours, availability of an attending radiologist to consult with
referring physicians, and decreased burden of daytime attending
radiologists. Academic radiology departments with residency training
programs are beginning to use ITARC at night. Although ITARC improves
patient care, it also affects the educational experiences of radiology
residents. These effects may vary depending on the interest in teaching
of the attending radiologist and the setup for both resident and
attending radiologist on-call coverage. Our data show that radiology
residents felt that ITARC improved their educational experiences.
International teleradiology attending radiologist coverage also
decreases radiology residents’ stress and anxiety related to on-call
shifts. Instant feedback and the ability to troubleshoot difficult cases
with an attending teleradiologist result in an enhanced night-float
experience without depriving residents of the ability to make
independent decisions.
REFERENCES
aDepartment of Radiology, Beth Israel Medical Center, New York, NY.
bDepartment of Radiology, Lenox Hill Hospital, New York, NY.
cDepartment of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pa.
Corresponding author and reprints: Sandor A. Joffe, MD, Department of Radiology, Beth Israel Medical Center, 1st Ave. at 16th St., New York, NY 10003. e-mail: sjoffe@chpnet.org.
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