Radiology Residency Night Float Vs. Standard Call- A Perpetual Controversy!!!

Blurry vision setting in; eyelids drooping just wanting to shut; difficulty communicating; and impending malaise. Rarely would I have any chance whatsoever to lay my head down even once. The films would just keep on streaming in.

These feelings were typical on that first night of call on a 1 or 2 week night float rotation block or the occasional Saturday overnight calls that we would have to do every once in a while. I dreaded those days. But, it is still standard for most radiology residency programs, even now. It is almost impossible to not have at least a few overnight shifts  like the ones I just described.

At one point or another, many radiology programs and radiology residents have come up with different schedules and options in order to minimize this extreme fatigue. Some have instituted night float schedules. Others maintain a standard rotating call schedule Q4,5, or 6. Some have long and short call schedules.

The choice to do one system or another is not so clear cut. Many considerations have to be taken into account before pushing for a decision to have either of these systems prior to implementation. Although I tend to favor the night float system, since I remember it personally mitigated fatigue after the initial day or two of call when I was taking overnights, the decision to have a night float program is probably not right for all programs.

So what are the factors that would lead one program to have a night float system and another to have a standard call system? Some of the issues that need to be addressed are: the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies,  and the emergency department requests. Also, I will also go through the disadvantages and advantages of each system that will also allow a program to make a determination of which system is best.

Factors For Instituting A Night Coverage System

Size of the Program

The smaller the program is, the less likely there will be adequate coverage for rotations during the day time, let alone the nighttime. In fact, at many programs, a small residency cohort prevents institution of a night float system. In a program with 3 or less residents per year, it may not be possible to have a resident out every night in order to be on call without severely compromising resident education. Also, it is possible that day time obligations cannot be covered if a night float system is instituted.

Attending Coverage

Institutions with attending and/or nighthawk coverage at nighttime allow more flexibility for scheduling of night float. In fact, some programs do not even need full time resident coverage during the nights and may share call obligations with attending coverage. Therefore, it is significantly easier to institute a night float system for the residency program.

Resident Preferences/Culture

In some residencies, the radiology residents have instituted a night coverage system that may be based upon the preferences of the individual residents. Many residents are fully invested in a given system. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or less call than they would have in the old system. So, the night coverage system in place becomes engrained into the fabric of the residency program.

Also, scheduling may be set up to accommodate specific residency daytime programs. A night time schedule may be coordinated so that it allows the resident to maximize daytime educational opportunities. At some programs, that may mean either a standard cyclical call schedule and for other programs, it may mean a night float schedule.

Program Director/Chairman Preferences/Department Culture

At many programs, the nighttime coverage is instituted by the leaders of the program, not the residents. Therefore, the coverage may be based upon the preferences of the program leadership. The program director or chairman may believe that a night float system or standard call schedule may be better for any given residency program. Or, perhaps there are coverage requirements that the department desires. In either case, it may not be a decision that is left to the residents.

Number of Studies

Perhaps you are a residency program that is a level 1 trauma center with significant numbers of ER studies at nightime. Some programs are so busy that they may need more than one resident or attending on call each evening. This may allow less flexibility to schedule a night float system since a program may not be able to accommodate the call coverage at nighttime.

Emergency Department Factors

Emergency departments may have specific requirements for the radiology coverage at nighttime. Some programs may only want to have senior residents to take call. Others specifically want attending coverage during the nighttime. Depending upon the demands of the emergency department, this may dictate the numbers, type, and presence of residents or attendings on call. A night float system or standard call system may have to be based upon the whims of the emergency department.

Advantages/Disadvantages of Each System

Night float

For most people, I personally think night float coverage for a week or two at a time mitigates fatigue the most. The body tends to get used to the night time schedule over time and allows the resident to function better on call. Sure, the first few days can be tough because the body and mind have to adjust. But overall, the experience is much improved.

On the other hand, when you are on a night float system, the resident may loose touch with the “educational” aspects of the residency program. You miss daytime lectures and conferences as well as attending readouts for long periods of time. While the time spent on night float is important for training, it is impossible to receive all the benefits of daytime resident education. You may lose out on understanding the context of the images that you are interpreting. Education in this sense may also be compromised.

Standard Call

Sometimes a Q4, 5, or 6 day call schedule integrates better with a program than a night float system and allows the resident to get a better overall experience. The resident does not miss out on all the noon conferences and educational experiences that they would be missing over a long block on a night float.

The two big disadvantages to the cyclical call schedule: significant overnight fatigue and the “lost day”. As I mentioned at the beginning, I always found it much more taxing to have an occasional overnight than a night float block, because my body never adjusted to the system. I think that this same issue can be extrapolated to most residents. In addition, the resident loses an extra day of residency experience every time he/she works because the resident is obligated to have a day off after call or “the post call day”. This can significantly decrease the educational opportunities for the resident.

Residency Call- Which System Should You Choose?

Night time call is an important facet of every radiologist’s education.  Whether or not you have a say in constructing your program’s night coverage system, you now realize that what works for one program, may not work for yours. The decision to have one or another system can be complex, but it is important to weigh each of the factors to come up with a final outcome. The key is to make the learning opportunity as pleasant as possible and mitigate fatigue. Hopefully your residency has chosen the most appropriate night coverage system for your institution!