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.

Twenty-six years ago I did an internship in internal medicine. I hated staying in the hospital overnight and the next day. I hated the pressure and responsibility of taking care of the sickest patients with little or no support. Still, I did my best and learned a great deal in the process of trying to put the theory of medicine into practice. Each morning, after another night from hell, as the smoke cleared, I knew I had jumped a good distance toward becoming a physician. I have used what I learned that year often during my radiology career.

The push for extending in-house faculty radiologist coverage to 24 hours a day/7 days a week in academic centers has been growing steadily. A desire to decrease medical errors and subsequent negative outcomes is the main cowboy riding this horse, a laudable goal. I am sure that the same push is going on in nonacademic centers and that there as well, no doubt, this goal has its unique set of challenges and controversy.

There are a couple of matters that concern me about this proposal, and none of them have to do with me personally. Our residents take evening and overnight call from the middle of their first to the middle of their third year. In our acute care hospital with a trauma center, they work very hard and face many simultaneous demands. They make critical care decisions with life and death consequences, just as I did in my medical internship. We use a night-float system, but as a rule, they are pretty chewed up in the morning. What amazes me is how quickly their overall radiologic knowledge and, more specifically, their recognition skills for radiologic pathology improve once they start call. They are supported until midnight by faculty and they have on-call subspecialty back-up; but for 7 hours they are the first line, the point people for the department. Occasionally, they make mistakes and, on very rare occasions, those mistakes are clinically significant.

Here are a few questions to consider. Do subspecialty radiology faculty, who read studies in a single imaging area, actually perform better than residents in training across all areas of imaging? Who are the best people to cover the graveyard shift--fellows, senior residents, younger faculty, faculty sent overseas to read online, or nighthawks of various aptitudes? Which approach results in the best-quality interpretation, consultation, and responsiveness? What harm can be done to the training of residents and their development of self-confidence and ability to work toward solutions to difficult cases if they are always under the direct supervision of a faculty member? Do we compensate faculty for being around and presumably awake all night? Do we compensate them with more money, more vacation, coffee, and "uppers"?

Here is the kicker. The goal we seek is to have care overnight equal to that during the day when the "experts are available," the labs are all open, special tests all obtainable, and so on. That suggests to me that we should have the same level of expertise available overnight in all areas of the medical service, all specialties. Not just on call, but there to see the patient, check every interns' and residents' work, and agree with their diagnosis and treatment plan before it is instituted. With all the head honchos around things would have to go more smoothly and medical care would certainly be better. Some departments (eg, emergency, trauma, and anesthesia) have been doing this for a long time. Why should the least experienced interns in medicine, surgery, obstetrics-gynecology, and psychiatry, etc. get to treat the sickest patients? Isn't that where we really need the maturity and knowledge of the seasoned veteran? There's always more room in the trenches.

I have no problem with 24/7 coverage. It's a good idea. I think patient care will be better and the stress on the residents lower. I just think we all need to play along.