Independent vs Supervised Call

[sievert_fever]

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How important is independent call?

I understand that it serves as a confidence booster. Some residents who have performed independent call assert, "I'd hate for my first unsupervised OR disposition to come as a junior attending." My thinking, however, is that any junior attending (with 5+ years of radiology experience) worth their weight in salt could call a borderline small bowel obstruction (0r comparable diagnosis) with reasonable confidence.

I obviously won't drastically change my rank list based upon call type, but I guess I'm asking whether to take it into consideration at all.

 

[qwerty89]

Of course its important to take it into consideration. Think about the internal medicine residents. When they are a senior resident they are expected to handle nearly all cross-coverage issues with ease and without attending support. Of course when **** hits the fan you page the in-house attending but the senior resident has already got the ball rolling and should be able to handle situations on their own.

Contrast that with a senior radiology resident working overnight with the attending at the next workstation...

The two educational experiences are not comparable.

 

[DrBowtie]

Very important. I'd say independent night float was the rotation I made the most progress in.

 

[Gadofosveset]

Independent call is important for a radiologist develop properly. A resident reads differently if he or she knows that a mistake will be caught in five minutes and cost them nothing.

Every training program knows independent call is important, even if they tell applicants that it's no big deal, but it's becoming almost impossible for programs to maintain independent call for their residents. In my experience, programs that manage to preserve some independent call, do so because they have a commitment to trainee learning.

 

[cowme]

Or they have a commitment to having less call for their attendings

 

[Gadofosveset]

Or they have a commitment to having less call for their attendings

The program will hire new attendings for those shifts.

Independent call is about the trainee experience. The trainee will be there anyway…. but call could be quality learning/growth time, learning to make decision on one's own, and prepping a report that's the final read for several hours… or it could be less useful time, just prepping reports for the attending in the other room.

 

[shark2000]

Independent call is one of the most valuable and important experiences that you can have as a resident.

 

[Radiologyreviews2015]

I feel like this is so rare now. I think maybe 1 of the 12 places I'm interviewing offers this. Not sure I'd rank them 1 solely based on this factor.

 

[Radiologyreviews2015]

A lot of places that have "independent" call still have ED radiologists, so they're not technically in the room.

 

[DrBowtie]

A lot of places that have "independent" call still have ED radiologists, so they're not technically in the room.

Independent call refers to solo resident coverage overnight with staff signing out in the AM.

Anyone who tries to spin the staff in the next room as independent is stretching.

 

[shark2000]

Independent call refers to solo resident coverage overnight with staff signing out in the AM.

Anyone who tries to spin the staff in the next room as independent is stretching.

4+.

It is a totally different world when the ED discharges that patient based on your report or when the surgery team takes the patient to the OR based on your report.

I know the trend is towards 24 hour in house attending which is very bad for resident education.

 

[maxxor]

It is a totally different world when the ED discharges that patient based on your report or when the surgery team takes the patient to the OR based on your report.

I know the trend is towards 24 hour in house attending which is very bad for resident education.

Can anyone name "good" programs that actually have independent call? I interviewed at a lot of places and only Hopkins still had it.

 

[sievert_fever]

Can anyone name "good" programs that actually have independent call? I interviewed at a lot of places and only Hopkins still had it.

From what I recall: UCSF, MIR, Emory, UVA, (Stanford and UTSW?... can't remember)

 

[CherryRedDracul]

From what I recall: UCSF, MIR, Emory, UVA, (Stanford and UTSW?... can't remember)

Yup, UTSW has independent call. UVermont also has independent call as well. University of Michigan has partial independent call from 3a-8a.

 

[Radiologyreviews2015]

Baylor, MUSC, and UNC do. Honestly, I've been to 19 interviews and lost my notebook of notes.

 

[Radiologyreviews2015]

I think UPMC has independent call but they only generate prelim reports... Correct me if I'm wrong.
Does anyone remember if Indiana does independent call? I can't remember.

 

[CorneliaSt]

I interviewed at mostly "resident driven" programs and it seemed about 2/3 of them had independent call. Mayo Rochester, Minnesota, and UChicago had independent call. I am fairly certain Wisconsin and Indiana also had independent call.

 

[chronicidal]

I interviewed at mostly "resident driven" programs and it seemed about 2/3 of them had independent call. Mayo Rochester, Minnesota, and UChicago had independent call. I am fairly certain Wisconsin and Indiana also had independent call.

At Mayo Rochester, the vice chair for education said there was an in house attending who is assigned to other tasks (??) so they're not reading from your list unless you call them. But then the residents said call was independent. Not sure what to think. Anyone else can clarify?

At Minnesota, all the overnight stuff gets a prelim report from a nighthawk radiologist. I don't think you can call that independent call if your prelims are going to be redundant with a telerads prelim generated around the same time. Anyone else can confirm?

 

[chronicidal]

Survey of chief residents on prevalence of 24/7 coverage: 'In 2015, 32% of programs reported having 24-hour in-house attending coverage, an increase from 20% in 2012 (P = .02) and a substantial increase from 2004, when the fraction was only 7%."

Multi-institutional survey (Cincinnati, Michigan, Yale, UWashington, Wisconsin, Ohio State) finds negative effects of 24/7 coverage on autonomy and educational experience: "Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage."

Tiny single institutional uncontrolled before-after study (at Einstein/Montefiore) finds no loss of perceived autonomy in 24/7 coverage: "Group 1 [with overnight attending] was more likely to report working at a comfortable pace (p = 0.008) and receiving attending feedback (p = 0.004) than group 2 [without overnight attending]. A non-significant trend towards reduced anxiety prior to NC was present in group 1 (p = 0.077). No difference in independence (p = 0.918), autonomy (p = 0.635), or confidence during (p = 0.431) or after NC (p = 1.00) was identified. DXIT [in-training exam] scores were not significantly different between the two groups (p = 0.396)."

Compiling a list of places with "independent call" (no 24/7 in-house attending coverage and no telerads prelims). Please copy and edit for corrections/additions/confirmations.

UCSF
MIR
Hopkins
Michigan
UTSW
Emory
UVA
UVermont
Baylor
MUSC
UNC
UChicago
Wisconsin
Indiana
maybe Mayo
maybe UPMC
maybe Stanford
maybe Duke
maybe UCLA

 

[meister]

Another thing to consider is whether or not you are required to generate full reports for each study or if you can ignore plain films and type "negative" into a CTPA study comment field, as examples.

There is a ton of variance here.

 

[elektroshok]

UTSW has full report independent call with big pressure from our administration to keep it that way. I don't see it changing anytime soon at least at our institution

 

[newdoc2013]

I think UPMC has independent call but they only generate prelim reports... Correct me if I'm wrong.

Correct. Responsible for anything and everything STAT at Presby/Monte, Mercy, Shadyside, Magee and CHP + whatever hospitals in western PA call you about. Its a great experience. FYI this includes high end studies such as skull base MRI, MRI/MRA/MRV, Body MR, CTA, T-bone CT, Max/Face CT etc.

 

[greg1184]

Survey of chief residents on prevalence of 24/7 coverage: 'In 2015, 32% of programs reported having 24-hour in-house attending coverage, an increase from 20% in 2012 (P = .02) and a substantial increase from 2004, when the fraction was only 7%."

Multi-institutional survey (Cincinnati, Michigan, Yale, UWashington, Wisconsin, Ohio State) finds negative effects of 24/7 coverage on autonomy and educational experience: "Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage."

Tiny single institutional uncontrolled before-after study (at Einstein/Montefiore) finds no loss of perceived autonomy in 24/7 coverage: "Group 1 [with overnight attending] was more likely to report working at a comfortable pace (p = 0.008) and receiving attending feedback (p = 0.004) than group 2 [without overnight attending]. A non-significant trend towards reduced anxiety prior to NC was present in group 1 (p = 0.077). No difference in independence (p = 0.918), autonomy (p = 0.635), or confidence during (p = 0.431) or after NC (p = 1.00) was identified. DXIT [in-training exam] scores were not significantly different between the two groups (p = 0.396)."

Compiling a list of places with "independent call" (no 24/7 in-house attending coverage and no telerads prelims). Please copy and edit for corrections/additions/confirmations.

UCSF
MIR
Hopkins
Michigan
UTSW
Emory
UVA
UVermont
Baylor
MUSC
UNC
UChicago
Wisconsin
Indiana
MCG
maybe Mayo
maybe UPMC
maybe Stanford
maybe Duke
maybe UCLA


My program has no 24/7 attending. There is limited overlap earlier in the weekday call, Solo call at night. Limited attending coverage during the day on the weekend. Unfortunately, upward pressures and pressures from other specialties (cough, ED) are making it more and more difficult because clinicians couldn't care less about "radiology education." They all care about getting their final reports now.

 

[DrBowtie]

Correct. Responsible for anything and everything STAT at Presby/Monte, Mercy, Shadyside, Magee and CHP + whatever hospitals in western PA call you about. Its a great experience. FYI this includes high end studies such as skull base MRI, MRI/MRA/MRV, Body MR, CTA, T-bone CT, Max/Face CT etc.

So what does your ER/Telerad section do or cover? They list 13 staff.

From the website it just looks like call at Pitt is inpts only and just prelims not dictated reports.

The devil is always in the details.

 

[qxrt]

I'm in a residency program that has independent call on some rotations, in-house attending call on other rotations. Honestly, I don't feel much of a difference between my confidence in calling cases when I'm with an attending or I'm alone. I find myself making the same search pattern and calls with or without the attending, and if anything, my work flow is a lot more efficient and faster on independent call without having to have an attending review each and every case I look at.

Honestly, the role of being on call is to make sure no one dies or gets injured in an avoidable and foreseeable accident. When you're on call, you're worrying about whether there's a pulmonary embolism, a dissection, or some other finding that might kill the patient that night or get them discharged from the ED when they should really be admitted. You're not coming up with broad differentials or nuances as to whether something is a lung cancer primary or a colon cancer primary. And when a case is borderline (e.g. "Is this appendicitis or a normal appendix?"), it's not an attending-level skill to describe what the concerning findings are and have the clinical team correlate with physical exam if it's an issue that might kill the patient that night.

In my experience, I feel like the importance of independent call is overblown by those who have only had experience in one or the other.

That said, I prefer independent call because, as I've said, it makes my workflow much more efficient. Not because I'm worried about my educational experience or whatever.

 

[scootad.]

^^You touch on something about independent call that hasn't been as emphasized. The speed factor. Yes, taking call by yourself is important in shaping your confidence and boldness in making life or death diagnoses, but it's also invaluable in making sure you can handle a HIGH VOLUME of cases coming at you all at once. Moving through a list fast and efficiently is essential for private practice.

 

[qxrt]

^^You touch on something about independent call that hasn't been as emphasized. The speed factor. Yes, taking call by yourself is important in shaping your confidence and boldness in making life or death diagnoses, but it's also invaluable in making sure you can handle a HIGH VOLUME of cases coming at you all at once. Moving through a list fast and efficiently is essential for private practice.

You might have gotten that backwards, at least in my experience. Being on call with an in-house attending has required me to become even more efficient because I have to factor in the time it takes to take the cases to them and review them, which is a pretty huge chunk of time when you're busy on call. When I'm on call by myself, I just need to look through the images and can put in my own impression quickly and efficiently. If anything, going from in-house attending call to independent call has made it much easier for me to keep up with studies without the time needed for attending review.

Keep in mind, the in-house attending wasn't there to help us residents with the worklist. They only read the studies that we brought to them (they took care of some other unrelated worklist we didn't cover in the meantime). In effect, we were the ones who managed them, by bringing the relevant emergent cases to them and putting off the non-emergent ones.

 

[DrBowtie]

You might have gotten that backwards, at least in my experience. Being on call with an in-house attending has required me to become even more efficient because I have to factor in the time it takes to take the cases to them and review them, which is a pretty huge chunk of time when you're busy on call. When I'm on call by myself, I just need to look through the images and can put in my own impression quickly and efficiently. If anything, going from in-house attending call to independent call has made it much easier for me to keep up with studies without the time needed for attending review.

Keep in mind, the in-house attending wasn't there to help us residents with the worklist. They only read the studies that we brought to them (they took care of some other unrelated worklist we didn't cover in the meantime). In effect, we were the ones who managed them, by bringing the relevant emergent cases to them and putting off the non-emergent ones.

Ultimately you both share the blame for any delays or misses.

Solo, it's sink or swim and the ER is blaming you alone if you're behind and you if you call in the morning with a serious miss.

And the difference between prelims and full reports is big time wise.

 

[qxrt]

Ultimately you both share the blame for any delays or misses.

Solo, it's sink or swim and the ER is blaming you alone if you're behind and you if you call in the morning with a serious miss.

And the difference between prelims and full reports is big time wise.

Definitely. The difference between prelims and full reports is a separate issue from independent vs in-house attending call, though. The volume at a big hospital would be too much at many places for the resident to put in full dictations, and not exactly the best use of on-call time, either. Who wants to be describing and dictating renal cysts or bone islands on call?

 

[DrBowtie]

Definitely. The difference between prelims and full reports is a separate issue from independent vs in-house attending call, though. The volume at a big hospital would be too much at many places for the resident to put in full dictations, and not exactly the best use of on-call time, either. Who wants to be describing and dictating renal cysts or bone islands on call?

Not sure if serious. Putting out full reports at any time of night is learning your future job. Not sure how your ER likes calling patients in the morning to tell them about their pulmonary nodule follow up or pelvic cyst follow up. I'm guessing they don't. Also don't describe clinically meaningless findings.

I'm skeptical of anyone touting their call volume experience without further clarification. Any claim of handling a list with two line prelims are bogus.

There are places out there that are level 1 trauma centers, full report, solo resident call handling ER and inpatients. Those are places I give the most credit to.

 

[shark2000]

Not sure if serious. Putting out full reports at any time of night is learning your future job. Not sure how your ER likes calling patients in the morning to tell them about their pulmonary nodule follow up or pelvic cyst follow up. I'm guessing they don't. Also don't describe clinically meaningless findings.

I'm skeptical of anyone touting their call volume experience without further clarification. Any claim of handling a list with two line prelims are bogus.

There are places out there that are level 1 trauma centers, full report, solo resident call handling ER and inpatients. Those are places I give the most credit to.

Agree. In house call without attending is a unique experience. Having an attending in house kills most of the educational opportunity. You have such experience during the day time. It is very valuable to have a different sort of set up during night time.

 

[shark2000]

You might have gotten that backwards, at least in my experience. Being on call with an in-house attending has required me to become even more efficient because I have to factor in the time it takes to take the cases to them and review them, which is a pretty huge chunk of time when you're busy on call. When I'm on call by myself, I just need to look through the images and can put in my own impression quickly and efficiently. If anything, going from in-house attending call to independent call has made it much easier for me to keep up with studies without the time needed for attending review.

Keep in mind, the in-house attending wasn't there to help us residents with the worklist. They only read the studies that we brought to them (they took care of some other unrelated worklist we didn't cover in the meantime). In effect, we were the ones who managed them, by bringing the relevant emergent cases to them and putting off the non-emergent ones.

Disagree. It is about making life saving decisions. Knowing that your interpretation will be checked by someone else in half an hour or one hour before the final clinical decision is made is way different than being the person who sends patients to OR or discharge them home.

It is not about the speed or cleaning the list. It is about being under pressure to make life saving decisions. And once an attending is there, you can not claim that you managed the patient. It was the attending who managed the patient.

You can't understand the value (and difficulty of solo call) unless you do it yourself or you start your first private practice job.

 

[badasshairday]

Solo call is super important. We have both. Our night float is solo for 11 hours at night. We have short call on weekday evenings and weekends 13 hour day time shifts, both of which have an attending reading not too far behind us. The night is a completely different beast when you can be reading something that will not be over read for 12 to 15 hours or more later. It is all on you. I definitely feel a difference. Yeah my search pattern is the same, but the stress level is totally different.

And about full reports and prelims. Guess what, when you are an attending with big boy pants on, you will always be doing full reports so better get used to it in residency itself.

 

[Dr. USMLE]

I personally do not feel any difference between true independent call versus in-house coverage (both final report). There may be one or two cases per night where deciding on the realness of a subtle finding may affect management in an emergent manner but just finding out more clinical info often resolves those issues. In general, ED radiology does not require much subspecialty expertise, which is why all attendings regardless of fellowship training are able to take call. It probably does "weed out" the slow or otherwise incompetent residents, but on the whole is no big deal, even in a busy level 1 trauma and stroke center.

What kind of serious misses are you guys making that result in all this pressure and learning? I might agree if residents were forced to take independent call in the first 6 months of residency. When it comes to differentiating between residents and even attendings, it is mostly based on ability to read MR, specialized CT (cardiac, perfusion, temporal bone, etc.), mams, and do non-fluoro procedures.

None of these areas are really stressed on call. There may be some MRs to rule out stroke, cord compression, and osteo, but those cases are the minority and there are often many ways to decide on subtleties. Besides, the stroke CT is really what guides emergent management. Neurosurgery is usually on board for suspected cord compression so that's at least double-read. Osteo can usually wait a few hours and is likely being treated empirically anyway. The rest is bread and butter.

 

[Gadofosveset]

Independent call is critical for developing your skills and ability to make decisions under time pressure and consult pressure. It's a simulator for real life. And it's a good simulator because you could screw up.

If one finds call unchallenging, then one is not being pushed appropriately in training. I've seen brilliant residents make real bone headed mistakes on call, mostly experience mistakes. Some residents (mostly seniors who think quite highly of themselves) make a lot of carelessness mistakes, too. When they miss metastases, small fractures, or give wrong follow up advice, I can only assume they're thinking, "I don't need to read it too closely, someone will over read me". Not a good training strategy.

In the same vein, moonlighting (reading studies) is the best resident experience possible.

 

[badasshairday]

Cases I can think of:
-Subtle flow artifact Versus true vertebral or carotid dissection on CTA neck trauma patient.
-missed closed loop obstruction
-normal noncon head ct for hemiparesis patient then missing the MCA occlusion on CTA due to beingredients faked out by branch vessel and collaterals. Lost chance for Endovascular therapy.
-ortho attending reviewing CT melodrama spine stat after stopping pediatric scoliosis correction surgery thinking maybe hardware missplaced... hardware looks good while reviewing with him... but then you both miss the epidural hematoma on CT.
-couple of flecks of free intra peritoneal air
-abd pain in ED, first CT shows colon cancer with lover mets. You slam dunk, but miss the single vertebral bone met and patient had compression fracture short time later.
-missed acute SMA thromboembolism.
-missed arcuate ligament.
-missed central liver lac
-is that little thing on the head CT a true lesion like stroke or mass? Well I'm signing out to attending so whatever, versus "dang no one is gonna see the for 12 hours so if I miss it i delay diagnosis or hurt someone, or I call something that's not there and buy myself more studies. "


These are examples from second year and early third year calls. Some happened with attending closely reading behind resident or 2 to 3 hour delay... others overnight with 10 to 15 hours delay. Some of the things may be things that you think no one should miss, I agree but we are still trainees. Not only that, I don't care how good you are, you will still miss things from time to time. The stress is different. You can be an over caller but then you get more studies to read, but you don't want to under call and make a miss. This is where I think independent call is clutch.

 

[tco]

Yeah, these are so awesome for learning.

Just hope that your family isn't the one you're learning on.

Such a selfish argument.

 

[DrBowtie]

Yeah, these are so awesome for learning.

Just hope that your family isn't the one you're learning on.

Such a selfish argument.

Same argument can be made for any specialty.

 

[tco]

Same argument can be made for any specialty.

Doesn't make it wrong.

 

[DrBowtie]

Doesn't make it wrong.

Just don't miss stuff

 

[tco]

Just don't miss stuff

Psh. Miss? They don't call me Mississippi for nothin'.

 

[qxrt]

Not sure if serious. Putting out full reports at any time of night is learning your future job. Not sure how your ER likes calling patients in the morning to tell them about their pulmonary nodule follow up or pelvic cyst follow up. I'm guessing they don't. Also don't describe clinically meaningless findings.

I'm skeptical of anyone touting their call volume experience without further clarification. Any claim of handling a list with two line prelims are bogus.

There are places out there that are level 1 trauma centers, full report, solo resident call handling ER and inpatients. Those are places I give the most credit to.

It's completely different being on call as a resident at a level 1 trauma hospital vs being the night float ED radiology attending for a random hospital. Of course you are supposed to put out full reports as the attending. When you are the resident, though, and handling over 100 cross-sectional studies, not including plain film responsibilities, in one night shift, doing full dictations on every case is not remotely possible. If you are at a place where doing full dictations on this type of workload is feasible, then clearly there is a difference in call volume that would account for the discrepancies.

 

[Dr. USMLE]

You guys act like residents could care less what their in-house attending thinks about them. At high volume large academic centers, you are expected to dictate so quickly that even if you want to ask your in-house about a case, there hardly seems to be time. You might ask about 1-3 cases in an entire shift and often part of the reason to ask is just to appease your attending's ROC/dictation preferences.

You are essentially flying solo, just without the collateral damage from more delayed corrections. I can't speak for others, but none of my co-residents project the attitude of "gee, my attending will overread this in an hour anyway so I don't really have to decide if this is stroke, heh."

I realize some residents will cut corners with a safety net and others learn best when it's trial by fire, but give me a break. Independent call is not different enough from in-house coverage to be some irreplaceable experience. It's not like an attending won't chastise you for missing an emergent finding 1 hour later, but will 10 hours later. There are plenty of residents I have met trained under both systems or hybrid systems and their ability to confidently take call is not appreciably different.

 

[Bradstein]

handling over 100 cross-sectional studies, not including plain film responsibilities, in one night shift, doing full dictations on every case is not remotely possible. If you are at a place where doing full dictations on this type of workload is feasible, then clearly there is a difference in call volume that would account for the discrepancies.

What programs have a single resident reading 100 cross-sectionals per night?

 

[tco]

What programs have a single resident reading 100 cross-sectionals per night?

That's stretching it, but at UT, we have reportedly 150-200 studies per night. I'm not sure of the total number of cross sectionals. Annnnd the volume has been steadily rising. Not all of those are final reports, obviously.

 

[blebb]

What programs have a single resident reading 100 cross-sectionals per night?

There's no way in a hell a single resident is dictating full reports for 100 cross sectionals. That's ridiculous. If it's true, that's very unsafe.

 

[LittleriRich]

The Medical College of Wisconsin has independent call from 8:00 pm to 7:3o am.

 

[Rad2013]

The difference between full reports vs "sticky notes" cannot be overstated.

 

[qxrt]

What programs have a single resident reading 100 cross-sectionals per night?

My program gets anywhere from 60-110 CT/MR/US studies per night, not counting plain films. My friend in another local program has similar volume. And both of our programs only require prelims, not final reads.

There's no way in a hell a single resident is dictating full reports for 100 cross sectionals. That's ridiculous. If it's true, that's very unsafe.

We do only prelim/wet reads at our program on call. Like i said, it is not possible to do full dictations on that kind of volume.

 

[DrBowtie]

Sounds like our M&M.

"GUYS -- YOU CAN'T MISS ANYTHING. LOOK AT THIS FINDING THAT 5 ATTENDINGS MISSED. MEDIOCRE!"

For the record I was being facetious.