Applied Radiology

Dr.Mirvis is the Editor-in-Chief of this journal and a Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

It's interesting that while medical professionals are usually fairly quick to adopt new discoveries in medical science, in diagnosis and treatment they tend to be rather reluctant to change how they do their everyday work. Even in radiology, where we are in the habit of adapting to new technologies in short order, we are much more hesitant to change how we practice the specialty. For most of its history, radiology has been a 9-to-5 specialty. The field can be attractive because of mostly regular working hours, relative insulation from direct patient contact (which is desirable for many), working with high technology, and high income. We considered it fine for our colleagues engaged in direct patient care to view "our" images when we were not around and to make their interpretations without our input until the next morning or even Monday morning. For many patients, our expert opinions often came well after diagnosis and treatment decisions were made, correctly or not. Somehow we were able to rationalize this arrangement as appropriate care. I think, on the whole, that radiologists thought of these circumstances as immutable, handed down from on high, and meant to continue ad infinitum. On reflection, I am amazed that we got away with it for so long.

Emergency physicians always knew that medical care was a 24/7 proposition, but sometime during the last 10 years, it dawned on administrators and risk managers that hospital care really worked this way as more and more patients were admitted emergently. People do not typically choose when to become ill. The idea came into fashion that patients should receive the same level of care, no matter what day or time they arrived. Clearly then, it was necessary to reallocate medical care resources to provide uniform quantity and quality of care at all times. However, the specialty of radiology was, in general, very content with its lot. The idea of "off-hours" coverage ran against the grain. The guiding principle for radiologist input was to provide timely consultative services for a patient's physician ¹ ; a rather vague and flexible guideline. Some inability to commit radiology resources for 24/7 coverage was due to real shortages of radiologists in many areas, making it difficult, if not impossible, to support this change--a fact that simply can't be ignored. However, with the advent of fast, dependable PACS and teleradiology, this limitation has become a far less valid excuse.

Today, we see a major shift in radiology practice to providing around-the-clock service. This is done with scheduling to include overnight reading, hiring "nighthawks" into practices, or using nighthawk services outside of the practice either in the U.S. or abroad. Given the real physiologic and psychological demands of overnight reading, it is not inappropriate for radiologists providing such service to receive greater compensation (both monetary and in terms of time off) than those working the daytime and evening rotations.

This transition has not been easy for many groups, both for personal and financial reasons, and there is still some resistance to it; but it is nevertheless necessary. In switching our own academic trauma/emergency department practice to 24/7 coverage, it was apparent that many of our usual practices would be upset. We typically had 10 to 15 CT and MRI studies waiting to be interpreted each morning, but now they are already dictated, so cases just trickle in during the day, making the rotation far less efficient at providing teaching material. The residents worried that having a full-time in-house attending radiologist would weaken their experience by decreasing the pressure on them to make quick, accurate interpretations while backup was just a few feet away. Our section members could go 3 to 4 weeks without seeing each other as they rotated through the various time slots (though, as it turns out, this can actually be a good thing). Communication between section members and within the department became more difficult. Collaborative writing efforts were hampered. There were too many residents during the day shift just sitting around, with few patients admitted and too few residents covering the evening and night shifts when admissions were in high gear. Clearly, dealing with these new conditions has been a challenge, and it will take creativity, patience, and, above all, a willingness to adapt in order to reoptimize our service.

Some radiologists might argue that the presence of attending radiologists adds little or nothing to the quality of interpretations that are already provided by residents, even those in the first 2 years of training, although this argument is debatable. ^2-4 Still, such studies miss the more ethereal factor of confidence in interpretation and subsequent guidance that comes from having an experienced staff member available as well as the clout to resist performing the wrong study and to perform an appropriate study, if needed.

In our section, we have seen and been told how much emergency and trauma physicians appreciate our constant availability and how it adds efficiency to patient care. We hope that our 24/7 presence really does positively influence patient outcomes, although that is difficult to document. Clearly, patient throughput in our system is more rapid, an effect we hope to verify in future research.

Adaptation to changing conditions is challenging, but resisting adaptation is the path to obsolescence. We all recognize that radiology is increasingly becoming the focus of diagnosis; we are indispensable. This is the reality we will live with, and it's a great situation for our specialty. To maintain this enviable position, we must overcome our business-as-usual tendency, step up to the plate, and deliver when it counts.