What makes residency call so stressful?

[odyssey2]

I hear constantly about how insanely stressful radiology call is. If you're a rads resident on an unsupervised overnight call shift, what makes it so uniquely stressful? Is there a safety net for you, and what are the repercussions if you make a bad call?

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[Cognovi]

It's not insanely stressful. It's only relatively stressful compared to the easy life of a daytime radiology resident.

The major factors are higher volume, frequent distractions, and higher stakes (given delayed supervision).

 

[Epi]

Probably depends on the residency. My residency the volume was high, and when cases required urgent reads so that decisions and treatments can be made, there isn't a lot of time to perseverate on what you see. Should the patient go to surgery or not? It can be a different feeling when you only have minutes to read a full body trauma CT with the surgeon calling you to ask what the results are so that they can decide if they need to take to surgery right now or wait a little bit. Can be juggling lots of issues at once, when you are the only person covering all modalities and the whole hospital, and the ER is never quiet. If there's something you dont see that requires immediate attention like type a aortic dissection, tension component to ptx, etc, unfavorable outcomes are more likely to happen, which can cause permanent disability.
Or situations like somebody comes in with hemoptysis, and you see findings that can be active TB but dont call it possible TB, its not on their radar, you don't mention it. The patient doesn't get put into isolation and r/o TB with precautions. Next morning on readout the attending is like this could be TB. Then the patient spent all night potentially exposing everybody and staff they interacted with to TB if indeed they had active TB. That was a big deal in our hospital if that happened, and it was more common than you think that people come in with active TB and not know it where I trained. Many different types of situation like that can occur.

 

[redoitall]

At our institution we have independent call. So sometimes, some calls are really hard to make ( Like a closed loop If you overcall it the patient gets a surgery he didn't need. If you don't call it, then the patients ends up with bowel necrosis). So there is some nerve wracking situations, but it's good to experience this while somehow in a safe setting.
For me, the big thing that is stressful is the constant phone calls. During peak hours, we have been receiving something like 15-20 phone calls an hour. Sometimes, these are situations that require some time while the list balloons.
I would say that if the phone calls were taken out of the equation (protocolling, contacting providers to tell them that they ordered the wrong study and what not, OKing a study, walking a provider through a ****ty read etc...), then call would not be that stressful, at least not out of the ordinary. Sure the volume can be daunting. I just had an unusually busy evening evening shift for 4.5h, ended up reading 29cts, 1MR, 5 US and 49 radiographs (I have had entire nights were I read less) but if I didn't have to constantly answer the phone, then I would feel more confident before signing the study, particularly when things are this busy. I probably would not go any faster, I don't think I can, but I think I would feel safer. This is what really adds to my stress while on call.

 

[CherryRedDracul]

Phone calls and IT issues (we have a ton of both). Otherwise, it's not that bad if you're a reasonably fast and accurate reader.

 

[Dave1980]

I went to a high volume program. We had 2 or 3 residents on depending on what time of night it was and we were all very busy the entire time. You would get up once or twice a shift to run to the bathroom and that's it. After 10 hours of that 6 nights in a row we were pretty burned out.

 

[dwills]

At our institution we have independent call. So sometimes, some calls are really hard to make ( Like a closed loop If you overcall it the patient gets a surgery he didn't need. If you don't call it, then the patients ends up with bowel necrosis). So there is some nerve wracking situations, but it's good to experience this while somehow in a safe setting.
For me, the big thing that is stressful is the constant phone calls. During peak hours, we have been receiving something like 15-20 phone calls an hour. Sometimes, these are situations that require some time while the list balloons.
I would say that if the phone calls were taken out of the equation (protocolling, contacting providers to tell them that they ordered the wrong study and what not, OKing a study, walking a provider through a ****ty read etc...), then call would not be that stressful, at least not out of the ordinary. Sure the volume can be daunting. I just had an unusually busy evening evening shift for 4.5h, ended up reading 29cts, 1MR, 5 US and 49 radiographs (I have had entire nights were I read less) but if I didn't have to constantly answer the phone, then I would feel more confident before signing the study, particularly when things are this busy. I probably would not go any faster, I don't think I can, but I think I would feel safer. This is what really adds to my stress while on call.

You read 30 cross sectional, 5 US, and 50 radiographs in 270 minutes while getting a phone call every 3 to 4 minutes? Seems way too busy for a resident, unrealistic when you factor in the phone calls.

 

[GadRads]

You read 30 cross sectional, 5 US, and 50 radiographs in 270 minutes while getting a phone call every 3 to 4 minutes? Seems way too busy for a resident, unrealistic when you factor in the phone calls.

Agree that this is dangerously busy for anyone. If you allot 60 mins to radiographs and US, you have < 7 mins per CT. Possible if these are mostly normal heads and C-spines, and only short prelim impressions are provided and not full reports.

 

[redoitall]

Agree that this is dangerously busy for anyone. If you allot 60 mins to radiographs and US, you have < 7 mins per CT. Possible if these are mostly normal heads and C-spines, and only short prelim impressions are provided and not full reports.

Yes I assure you that these were the number of reads and full ones at that. As far as phone calls, we are two residents taking turns, so it is more like 1 phone call every 8 min on average. Our reads are full reads and not short prelim. That said templates help speeding things up. Out of these only 1 short prelim which was a brain MRI. It was a routine that had a stroke and a cancer mess. So on this, reported the stroke, paged and talked to the doc. But everything else was full reads. I wish all were normal but they were not. A couple of these patients were traumas with acute findings (we are a trauma I center). Several abdomen and chests, some normal, one had a few PEs. One was a major cancer bomb that took a good 10 -12 min to dictate at least.
I have to take a few shortcuts: pulmonary nodules, lymphadenopathy reporting are subpar when the list blows up. Cysts, bone island and full spondylosis description also take a cut.
I agree that this is dangerous. Mind you, we have residents even faster than that. I think I could not have gone faster without being unsafe.

Now I will not comment on the morale in our residency program. Suffice it to say, that I am personally burnt out, pushed to the brink of exhaustion and depression. We do ~ 4 months of nights a year (R2 and R3) and 2 or 3 months during R4.

 

[Dave1980]

Yes I assure you that these were the number of reads and full ones at that. As far as phone calls, we are two residents taking turns, so it is more like 1 phone call every 8 min on average. Our reads are full reads and not short prelim. That said templates help speeding things up. Out of these only 1 short prelim which was a brain MRI. It was a routine that had a stroke and a cancer mess. So on this, reported the stroke, paged and talked to the doc. But everything else was full reads. I wish all were normal but they were not. A couple of these patients were traumas with acute findings (we are a trauma I center). Several abdomen and chests, some normal, one had a few PEs. One was a major cancer bomb that took a good 10 -12 min to dictate at least.
I have to take a few shortcuts: pulmonary nodules, lymphadenopathy reporting are subpar when the list blows up. Cysts, bone island and full spondylosis description also take a cut.
I agree that this is dangerous. Mind you, we have residents even faster than that. I think I could not have gone faster without being unsafe.

Now I will not comment on the morale in our residency program. Suffice it to say, that I am personally burnt out, pushed to the brink of exhaustion and depression. We do ~ 4 months of nights a year (R2 and R3) and 2 or 3 months during R4.

Is your program in Pennsylvania? Sounds like mine.

 

[redoitall]

Ahahah. No, in Texas... Won't get any more specifics though.

 

[Clean7795]

Traditionally radiology residents have been the busiest residents on call on average (i.e. back when most or all programs were 24 hr call and had no attending coverage overnight). This is probably changing or has changed at places where there is now attending coverage overnight.

Radiology residents also usually deal with acute and hyperacute cases overnight more so than most other residents. This part eventually becomes less stressful though since you are trained to handle it and get used to it.

 

[Cognovi]

This thread makes clear to me that the primary determinant of overnight call stress is the interaction of case volume and distractions, and that this differs substantially between programs. I recommend applicants get very specific when they ask residents when interviewing:

• "call" is defined as shifts outside of the business day/week (eg, evenings, nights, weekends)
• how many days/weeks of call do you have during residency total?
• how long is a typical shift?
• how many full dictations do you complete on a typical shift?
• how many prelim/sticky note interpretations do you provide?
• what is the mix of these dictations by CT/MR vs. US/XR?
• do you have others working on the list at the same time (eg, another resident, an attending)?
• do you have a secretary helping answer phone calls?

Compared to the poster above, my program's nights experience is probably two-thirds as intense and one-third as frequent. I know of programs that are less intense as well.

 

[Neopolymath]

This thread makes clear to me that the primary determinant of overnight call stress is the interaction of case volume and distractions, and that this differs substantially between programs. I recommend applicants get very specific when they ask residents when interviewing:

• "call" is defined as shifts outside of the business day/week (eg, evenings, nights, weekends)
• how many days/weeks of call do you have during residency total?
• how long is a typical shift?
• how many full dictations do you complete on a typical shift?
• how many prelim/sticky note interpretations do you provide?
• what is the mix of these dictations by CT/MR vs. US/XR?
• do you have others working on the list at the same time (eg, another resident, an attending)?
• do you have a secretary helping answer phone calls?

Compared to the poster above, my program's nights experience is probably two-thirds as intense and one-third as frequent. I know of programs that are less intense as well.

I'm concerned about asking these types of questions on interviews because I don't want to come off as a slacker. Obviously no pre-interview dinner so we will see if there are candid opportunities to ask the real questions during virtual meetups.

 

[redoitall]

I'm concerned about asking these types of questions on interviews because I don't want to come off as a slacker. Obviously no pre-interview dinner so we will see if there are candid opportunities to ask the real questions during virtual meetups.

I hear but I will second what was said before. Make sure to talk to current residents and really listen to what they say.
I can tell you that what was sold to me and what I bought were two very different things, and I am not counting my regrets any more...
So be super specific and make sure you ask all the questions above!

 

[Dave1980]

At some point we literally couldn't keep up with the volume with 3 residents on overnight so they let us start putting prelims on inpatient body CT...that was a real game-changer since they typically did all the C/A/P for inpatient cancer staging overnight.

"No acute issues...full dictation to follow."

 

[GadRads]

Yes I assure you that these were the number of reads and full ones at that. As far as phone calls, we are two residents taking turns, so it is more like 1 phone call every 8 min on average. Our reads are full reads and not short prelim. That said templates help speeding things up. Out of these only 1 short prelim which was a brain MRI. It was a routine that had a stroke and a cancer mess. So on this, reported the stroke, paged and talked to the doc. But everything else was full reads. I wish all were normal but they were not. A couple of these patients were traumas with acute findings (we are a trauma I center). Several abdomen and chests, some normal, one had a few PEs. One was a major cancer bomb that took a good 10 -12 min to dictate at least.
I have to take a few shortcuts: pulmonary nodules, lymphadenopathy reporting are subpar when the list blows up. Cysts, bone island and full spondylosis description also take a cut.
I agree that this is dangerous. Mind you, we have residents even faster than that. I think I could not have gone faster without being unsafe.

Now I will not comment on the morale in our residency program. Suffice it to say, that I am personally burnt out, pushed to the brink of exhaustion and depression. We do ~ 4 months of nights a year (R2 and R3) and 2 or 3 months during R4.

I think I know your program and I interviewed here. I got this vibe and I ranked it low. In all my 4 years of radiology residency, I won't do more more than 2 months of overnight call in total. Between two people on our 10-12 hr overnight calls, we read between 80-100ish CTs, 100-150 plain films and 5-15 US, and <5 MRs thrown in. We always do full reports. They are usually busy shifts, but nothing like your program which seems to run at a pace that I would still consider dangerous. At that pace, for example, you can miss a thin isodense/mixed density subdural bleed, and God forbid the patient gets anticoagulation, or other subtle findings with important short- and long-term clinical ramifications. The residents in your program are most certainly burnt out.

People at times state you can read super fast and still be very accurate. That is a poor metric since most studies (>50%) do not contain clinically actionable findings. The better yardstick would be to ask "In a sample of positive studies, what's the radiologist's accuracy?" This latter question is even more difficult since we never see or come to identify the true gamut of positive studies. We can never be sure we are documenting the true denominator (that is, all the positive studies). So this becomes a point of endless debate.

 

[redoitall]

They are usually busy shifts, but nothing like your program which seems to run at a pace that I would still consider dangerous. At that pace, for example, you can miss a thin isodense/mixed density subdural bleed, and God forbid the patient gets anticoagulation, or other subtle findings with important short- and long-term clinical ramifications.

I could not agree more with you. We all miss. I also noticed that my miss rate increases with speed obviously. My tactic then is to skip the useless stuff and not report or even look for them.

The residents in your program are most certainly burnt out.

You have no idea...

People at times state you can read super fast and still be very accurate. That is a poor metric since most studies (>50%) do not contain clinically actionable findings. The better yardstick would be to ask "In a sample of positive studies, what's the radiologist's accuracy?"

That would actually be a great study to do. However, where I come from, we have constantly argued that our workload, calls and obligations are not realistic. Out of a survey we did, we are more than 3 standard deviation in the number of call hours. There have been committees, discussions for over a year now and very little has happened. Instead negative changes have taken place that either limit our abilities to do what we want with our own time, or vacation policy that has become more stringent, or additional obligations while on call (like look at Urgent studies and report any findings). These get enacted in less than 1 week.

After 1 year of bitching and yelling, we got a reduction in the number of call hours by approx 3% or so. Yeah....... We are still 3 sd away.

Not sure if you indeed know which program I am in, but if you avoided it, then it was a master move. The issue is not the education we get, the attendings are great (well most of them), and we are getting great training. The issue is that we are miserable getting it. Many places do it just as well with happier residents.

I have had my shares of bad decisions. But deciding to enter this program, is up there. It is unfortunate to think so when I think of all the people I work with, the residents to start with, many of the attendings which are awesome. But the policies are dumb and the culture out of this world, and all too often in the way of favorable and positive changes...

 

[Cognovi]

Out of a survey we did, we are more than 3 standard deviation in the number of call hours.

Does anyone know of any published data on this question (quantified call burden during radiology residency)? I would be curious how my program compares.

 

[redoitall]

Does anyone know of any published data on this question (quantified call burden during radiology residency)? I would be curious how my program compares.

I honestly don't know. That would be a great study to do actually. I have to say that from memory it was voluntary participation and I believe 40 ish program participated (but do not quote me on that, it could be half). We got the data over a year ago, so I don't really remember.

It would be very nice if we could have an exhaustive study with force participation of all programs. But when your attendings keep telling you that you are taking too much call, and that's nothing like they did during residency (for the ones who didn't train here), you kind of feel something is out of place.

 

[Clean7795]

For medical students, IMO having busy call is fine and to an extent good because it will force you to learn to be fast and develop search patterns for actionable findings overnight. Having frequent call is bad because it will take away from your day time learning at the workstation/rounds (plus the obvious effect on your sleep & health).

 

[CherryRedDracul]

At some point we literally couldn't keep up with the volume with 3 residents on overnight so they let us start putting prelims on inpatient body CT...that was a real game-changer since they typically did all the C/A/P for inpatient cancer staging overnight.

"No acute issues...full dictation to follow."

Our inpatient volumes are pretty high so we do have a dedicated resident for preliming the inpatient CTs.

 

[Bayonetwork]

Interesting some folks at busy programs mention prelims on overnight/ER/call studies. I’m at a grindy list first/didactics distant second hybrid program and we don’t do prelims because it’s so busy and no attending/resident wants or has time to go back through and finish or re-dictate all those reports. Daytime shifts are already busy, ER/call shifts are just stupid busy.

 

[Clean7795]

Interesting some folks at busy programs mention prelims on overnight/ER/call studies. I’m at a grindy list first/didactics distant second hybrid program (avg weekend ER shift 8a-8p is 150-200 studies ~80-110 CT, 5-10 MR, rest plains and U/S) and we don’t do prelims because it’s so busy and no attending/resident wants or has time to go back through and finish or re-dictate all those reports. Daytime shifts are already busy, ER/call shifts are just stupid busy.

Is that a single resident handling all of that or multiple?

If it's a single resident, those must be incredibly simple studies with a high rate of straight normals because you're averaging ~3 minutes per study for 200 cases over 12 hours. I can't imagine averaging 3 minutes when there are an abundance of CT stroke angios, malignancy workups, pan scan traumas, complicated postop heads/bellys, etc. Final reports where I am on things like MR spines have level by level details that take longer than 3 minutes to dictate let alone look at.

 

[guytakingboards]

Interesting some folks at busy programs mention prelims on overnight/ER/call studies. I’m at a grindy list first/didactics distant second hybrid program (avg weekend ER shift 8a-8p is 150-200 studies ~80-110 CT, 5-10 MR, rest plains and U/S) and we don’t do prelims because it’s so busy and no attending/resident wants or has time to go back through and finish or re-dictate all those reports. Daytime shifts are already busy, ER/call shifts are just stupid busy.

Yea i call BS on residents doing that in a 12-hr shift.

 

[sievert_fever]

Agreed. Dude is obviously just trying to flex. That's like double what a real 12 hour shift is.

 

[Cognovi]

Agreed that is double what a 12 hour shift at my program is.

 

[chudat]

Lol 80-110 cts in a 12hr shift plus mrs, plain films and us.

....oh final reads too??

Lmao

 

[Bayonetwork]

150 ER studies on an average night and up to 200 when it’s stupid busy is very high volume but very doable. Solid templates, dialed in macro/pick lists, efficient search pattern, good PACS and good techs make all the difference. Get quick at handling phone calls. If a doc/resident calls I give them 20-30s before I cut them off and say what’s your question, don’t let them or yourself ramble. We take a TON of call from late R1 to mid R3, obviously you don’t start reading 175 studies day 1 but you get there quick or you’ll stay drowning and miserable. Nows the time to push yourself while your “protected.” Get out of your comfort zone, if your not missing things from time to time your not moving quick enough. Early R2 year I missed a vert injury and was bummed but the attending said “good I hope you miss it 5 more times, that’ll be 5 more cases of X pathology you’ll never forget.” Y’all can call BS all you want but there are plenty of residents/attendings crushing lists out there and not missing at any higher rate than average. You don’t need to be dictating prose, geek paragraphs or grammatically perfect reports with every renal cyst in full detail in the ER. Get to the point and answer the clinical question/indication as best you can and move on. Crafting a simple but effective impression quickly is an artform, learn it.

 

[sievert_fever]

Ah, SDN. Thank you for patronizing a bunch of radiologists who are likely more senior than you. We are just pointing out to the more junior folks that your numbers are almost certainly embellished and in private practice would represent >90th percentile of productivity.

 

[Bayonetwork]

Ah, SDN. Thank you for patronizing a bunch of radiologists who are likely more senior than you. We are just pointing out to the more junior folks that your numbers are almost certainly embellished and in private practice would represent >90th percentile of productivity.

As someone currently on the job hunt, 80 cross-sectional on a 12-hr ER shift I can assure you is out there. Over 100 would be >90% for sure but even then 10% is still a lot of radiologists. The second someone mentions high volume people get upset as if someone challenged their work capacity/skill. No ones faulting someone for reading more or less were all on the same team, some are just faster than others. There are many places out there with attractive salaries for a reason and not many folks wanting to do ER work. Incidentally I’ve noticed burnt out or unsatisfied colleagues are often on the slower side and probably over-represented on these types of forums. Just a guess but probably not far off.

 

[GadRads]

As someone currently on the job hunt, 80 cross-sectional on a 12-hr ER shift I can assure you is out there. Over 100 would be >90% for sure but even then 10% is still a lot of radiologists. The second someone mentions high volume people get upset as if someone challenged their work capacity/skill. No ones faulting someone for reading more or less were all on the same team, some are just faster than others. There are many places out there with attractive salaries for a reason and not many folks wanting to do ER work. Incidentally I’ve noticed burnt out or unsatisfied colleagues are often on the slower side and probably over-represented on these types of forums. Just a guess but probably not far off.

80 CTs in 12 hours is doable assuming these are somewhat routine with a bunch of normal CT head and spines thrown in. But this will be a VERY busy shift with a risk of missing subtle findings or the occasional 2-4 mm lung nodule. If you are handling phone calls as well, then it is even more brutal. I have been on 9-hour CT calls focusing on chest, abdomen and pelvis, and it is unusual for anyone to read more than 35 CTs. Some of these CTs are complex and can take even our subspecialty body attendings 35+ minutes to review.

The faster you read, the more you miss. And what you are willing to miss depends on your level of comfort.

 

[guytakingboards]

Dunning-Kruger alert

 

[GoPelicans]

The phone calls and interruptions single handledly make me hate call. Eliminate those two things and it's just fine.