Independent vs Supervised Call

[qxrt]

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We do full dictations overnight for all modalities. How does a prelim/wet read differ from a full dictation? I imagine you still go through your whole search pattern.

Of course we go through our whole search pattern. The prelim read is not an excuse to just skim through a study and neglect small findings; we are just much more selective in what we mention.

For example, a negative head CT for trauma would get "No fracture or hemorrhage" or something akin to that. Or a follow-up head CT for hemorrhage would say "stable left holohemispheric subdural hematoma and calvarial fracture as seen on prior study" if that were the case.

It's kind of like skipping the whole findings section of the report and going straight to the impression.

 

[maxxor]

Of course we go through our whole search pattern. The prelim read is not an excuse to just skim through a study and neglect small findings; we are just much more selective in what we mention.

For example, a negative head CT for trauma would get "No fracture or hemorrhage" or something akin to that. Or a follow-up head CT for hemorrhage would say "stable left holohemispheric subdural hematoma and calvarial fracture as seen on prior study" if that were the case.

It's kind of like skipping the whole findings section of the report and going straight to the impression.

Yeah this doesn't happen where I am. We are expected to dictate entire reports. However, there is a prelim tool that documents who and when we gave a verbal prelim (usually at scanner or when they walk in for consult) and don't have time to give entire report.

 

[HandOfMrsRoentgen]

Of course we go through our whole search pattern. The prelim read is not an excuse to just skim through a study and neglect small findings; we are just much more selective in what we mention.

For example, a negative head CT for trauma would get "No fracture or hemorrhage" or something akin to that. Or a follow-up head CT for hemorrhage would say "stable left holohemispheric subdural hematoma and calvarial fracture as seen on prior study" if that were the case.

It's kind of like skipping the whole findings section of the report and going straight to the impression.

Yeah this doesn't happen where I am. We are expected to dictate entire reports. However, there is a prelim tool that documents who and when we gave a verbal prelim (usually at scanner or when they walk in for consult) and don't have time to give entire report.

When I was interviewing, the programs where one dictated full reports sold it as "when you're out in practice you will be dictating full reports anyway", whereas the programs where one just had to put in a short prelim read sold it as "if there is time to dictate full reports overnight they clearly don't have the volume that we do".

 

[Shifty B]

Regarding the safety of residents working alone at night, I'll make a few comments.

First, it's not that dangerous. There is a substantial body of literature showing that discrepancy rates are similar to attendings overeading each other. Plus, those studies are overread the next day, and there are a scant few diagnoses where you can't safely get someone through to the next day safely, especially in an academic center where subspecialists look at their own studies and if they are concerned, they will admit the patient.

Second, for those of you who are acting like you don't want radiology residents experimenting on their family members, consider this. It is a different feeling knowing that you are the most experienced radiologist in the hospital and having to make a call that will send someone to the OR. I'll liken it to the difference between taking a free throw in overtime when you are down by 1 versus when your team is already ahead by 30. You need to feel that, and if you don't during your residency, it's going to happen at a different hospital on your first day as staff, where no one ever sees that study again. That's arguably more unsafe. There are a lot of ways you can achieve this, and at some places they may even when an attending is in house with you. If you're reading out at night likely you read out during the day (only it's dark outside), that's a problem.

Finally, I'm inclined to believe that residents that are forced to generate full reports are better prepared for private practice volume. It requires greater efficiency and makes you more accountable for your findings. I don't feel that strongly about this or have great evidence to support my opinion, but it is how I feel.

 

[Bradstein]

Regarding the safety of residents working alone at night, I'll make a few comments.

First, it's not that dangerous. There is a substantial body of literature showing that discrepancy rates are similar to attendings overeading each other. Plus, those studies are overread the next day, and there are a scant few diagnoses where you can't safely get someone through to the next day safely, especially in an academic center where subspecialists look at their own studies and if they are concerned, they will admit the patient... if you don't during your residency, it's going to happen at a different hospital on your first day as staff, where no one ever sees that study again. That's arguably more unsafe.

I agree completely.

 

[atalmatal]

Can you please reference some of this data showing that the discrepancy rates are similar?

 

[Radiologyreviews2015]

The best is independent call where you can prelim and leave and don't have to fully dictate and read out the next morning. The day people would double read what was done overnight. The most painful is the 8AM readout and full dictations. That can last until lunch time.

 

[Radiologyreviews2015]

Can you please reference some of this data showing that the discrepancy rates are similar?

https://apdr.org/uploadedFiles/Members_Only/ACGME_Appendix_1.pdf

 

[Shifty B]

Faculty discrepancy rates range from about 0.7%-3.6% based on type of study, who overreads whom, etc. The most recent large study (approx 135,000 cases) had a major discrepancy rate of 1.7% for residents when overread by subspecialty attendings.

See the attachment.

 

[chronicidal]

Faculty discrepancy rates range from about 0.7%-3.6% based on type of study, who overreads whom, etc. The most recent large study (approx 135,000 cases) had a major discrepancy rate of 1.7% for residents when overread by subspecialty attendings.

See the attachment.

Ah so this is the study that UTSW uses to protect its independent call.

 

[Shifty B]

Perhaps, but this study only confirms what has been shown in multiple studies (several of which are referenced in that paper): there is relatively low discrepancy rate of residents taking call that is similar to that of attending vs. attending reads.

Having a 24 hour attending is justified by anecdotal stories of resident misses and discomfort of emergency departments in being unable to say a read is "final", which results in sometimes calling patients back from home. It may not make a patient safer, but it does make hospital administrators feel better.

Delaying responsibility and infantilizing residents also has some effect on training as well, but it will likely never be well quantified because it would require taking two cohorts of residents and randomizing them into two groups, one with attending coverage 24 hours and one without, to see which improve faster.

 

[chronicidal]

Perhaps

I heard the UTSW PD say 1.7% when talking about using the discrepancy rates at their institution to assuage the ED and trauma surgeons.

 

[cbtk18]

Independent call at my shop with full reports. Anywhere from 50-100 cross sectional per night. Level 1.

Lots of pressure lately from the surgeons and other clinicians to have in house attending coverage or at least night hawk. Over the last couple of weeks they've forced the night resident to call and wake up the attending for dumb stuff (ie a very obvious appendicitis). Very passive aggressive. Rad attendings obviously doing everything they can to fight it. Some agree that it's a losing battle.

 

[meister]

100 cross sectional studies in a night? Do you get to ignore plain films and ultrasound or something? If there's just one of you that's insane unless they're all head CTs...

 

[cbtk18]

100 cross sectional studies in a night? Do you get to ignore plain films and ultrasound or something? If there's just one of you that's insane unless they're all head CTs...

No plain films