RSNA 2017: Resistance voiced against round-the-clock attending coverage

The time has not come, and probably never will, for academic medical centers to adopt 24-hour coverage by expert attending radiologists. In fact, the traditional model—overnight ER coverage by radiology residents with trust-but-verify oversight by faculty members—is not only up to the task but superior to the up-and-coming way.

So contends Michael Bruno, MD, of Penn State Hershey Radiology, who stood alone with this position in a panel discussion Nov. 27 at the annual meeting of the Radiological Society of North America in Chicago.

Arrayed against Bruno were Hani Abujudeh, MD, MBA, of Cooper Medical School at Rowan University in Camden, New Jersey; Jonathan Mezrich, MD, JD, MBA, of Yale; and session moderator Howard Paul Forman, MD, also of Yale.

“It’s been argued that it’s simply and obviously better to have an attending [on duty] at night than [to have] a traditional academic and that we owe it to our patients to provide the highest standard of care,” Bruno said. “Well, a large number of careful studies have shown that residents are at least as good—and probably have a higher accuracy—for emergency radiology studies than attending radiologists.”

Bruno made the case that the loss of a faculty overread step eliminates the benefit of double reading for error mitigation and prevention of patient harms.

“There are practical staffing considerations that further worsen quality and disparity,” he said. “I believe it is very harmful to the educational mission [of the institution], and I don’t think it’s worth the cost.”

Rad residents second to none

Presenting numerous peer-reviewed studies drawing from tens of thousands of patient cases in recent years, Bruno pointed out that the literature “consistently shows that residents actually have a higher accuracy than attending radiologists.” Meanwhile, overreading by subspecialist faculty—which is part of the standard academic model—also preserves a 24-hour subspecialist level of care, he said.

“This distinguishes the academic medical center from the private-practice medical groups,” Bruno said, adding that private-practice groups give their communities a standard of care that is based on general radiology.

“The loss of that subspecialist faculty overread in the new model creates a lower standard of care at night,” he said. “You have a generalist standard of care in the night and a subspecialist standard for the day. And I don’t think that’s right.”

Bruno ran through data and research supporting his thesis, then closed with several questions for attendees to consider, including:

• Does the perceived need for speed in the emergency department truly justify having a lower standard of care for night patients as opposed to those [seen] during the normal work day?
• Does the improvement in radiology report turnaround times and a modest reduction in the hassle factor for those few patients who have to be called back justify the high cost of overnight attending coverage—especially when it appears likely that patient outcomes will not be improved?
• Do we not have a duty or an obligation to preserve the training experience that has served our profession and the public well for generations?

Bruno closed with a quote from the late management guru Peter Drucker:

“The race for quality has no finish line—so, technically, it’s more like a death march.”

First-person patient view

Forman synopsized the counterpoint to Bruno’s argument with a provocative proposition.

“If you’re in favor of only having a resident in the ER, then you should also be in favor of basically demanding that a resident take care of you or your family in the ER, in the interest of [furthering the resident’s] medical education—and try to exclude the attending or a fellowship-trained physician as much as possible,” Forman said. “I say this tongue-in-cheek to some extent, but as someone who has spent well over three dozen days in the hospital—as a patient who has had multiple surgeries—I liked having an attending surgeon in the room even though I knew that the chief residents and senior residents do a very good job.”

Forman emphasized that his viewpoint acknowledged the better training residents would surely get were they allowed to take care of patients on their own.

“I don’t dismiss the fact that independence has a real impact on people’s development of confidence,” he said. “We have 20 years of experience at Yale seeing how our residents develop, watching them go from residents to fellows and then to attendings working in our emergency room [at Yale-New Haven Hospital]. We know that, yes, there is a change in experience when you are fully exposed to all of the sort of liability—real or perceived—when you go from being the second reader of a study to the first reader. But it’s still part of our imperative, from an ethical and moral point of view, to provide the highest level of care.”