Tag: call

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Top Ten Signs You’re Not Ready For Call

ready for call

Last week we discussed the Top Nine Signs You Are Ready To Take Call. So, I figured I would not do justice to the topic of being ready for call without also creating a list of those signs that you might not be ready to take radiology overnights. Therefore, I have dedicated this list to those that think they are ready but are not. Maybe this is you? Check it out if any of these signs apply to you!

Never Double Checks Anything (Anything Goes!)

Our words matter, and anything that you say, the ER can use against you later on. If you recommend another test, guess what? You will probably get that test the same night! So, the resident who never checks their dictations to make sure everything makes sense and is corrected is in a world of hurt.

Anger Management Issues

If you constantly fight with your fellow residents or, even worse, your faculty, you probably need to settle down a bit before taking overnights. Ready residents can control their anger and not take it out on others because they know what they are doing. If you are in the former category, think about why that is!

You Repeat The Nighthawk Dictation Verbatim

If you rely on the nighthawk dictation as a crutch, it probably means you are not ready to strike it out on your own. You should go through every case as if it is new, even if another radiologist has already dictated it. You never know what they are going to miss. And, you certainly don’t want to miss the same things!

Never Looks Up History/Priors/Call For More Information

If you think you know it all and don’t ever need additional history or the need for priors, you are in for a rude awakening. The number of findings that you miss will be incalculable. And, you will miss the point of your imaging studies more often! It is one surefire way to mess up your cases at nighttime!

Assumes The History Is Correct And Relies On It Explicitly

Using history as a crutch is an elementary mistake that can lead to disaster. I can’t tell you how often the ER calls for hepatobiliary scans to rule out cholecystitis, even though the patient doesn’t even have a gallbladder! We need to check and recheck our work and compare it to priors to ensure we are doing a good service for the patient!

Disorganization And Routinely Forget Cases

If you forget to read films or complete your work during the daytime, do you think you will remember to finish everything at nighttime? Disorganization can lead to disaster. You can wind up dictating the wrong case on the wrong patient if you don’t watch what you are doing. So, get yourself into shape before starting!

Cannot Get Through The Daytime Cases on Time

It’s not just accuracy that matters at nighttime. Speed is critical as well. And, if you cannot get through work during the daytime, what makes you think you will get through everything at night? Cases will often come in batches, and everyone needs a timely report when this situation happens. Make sure that you are up to the task!

Only Knows The Aunt Minnie Diagnoses And Never Scrolls Through Cases

There is a big difference between knowing the diagnosis based on a solitary image and having to make your finding on an entire case that has hundreds of pictures. If you think you can get through your studies without the experience of scrolling through lots of cases, you will have lots of problems when you have to make all the findings at night.

Unintelligible Dictations

Do your attendings always tell you to edit your dictations because they can’t understand what you are trying to say? Well, listen to these folks very carefully. Dictations are the final product of what radiologists do. And, if you cannot say something intelligible, you have no business being on call!

Lack Of Rigorous Search Patterns

Every resident needs a rigorous search pattern when they are working at nighttime. Lacking a search pattern is a recipe for missing all the critical findings. If you never look for the spleen, you will never know it is absent. And so on. Hone in on your search pattern skills before starting to take call!

Are You Not Ready For Call Yet?

If one or more of these signs describes you, you may not be ready to take your first call. However, there is still a bit of time. So, go ahead and make adjustments before it’s too late!

 

 

 

 

 

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Top Nine Signs That You Are Ready To Take Call

take call

Are you wondering if you are at the level of a second-year resident, ready, able, and willing to handle overnight shifts independently so early in the year? Here are the top nine ways you know if you are prepared to take call!

Methodical Thinking/Search Patterns For Each Imaging Study

Do you have a search pattern for every case you attempt to tackle? When reading a CT scan, you should have the same search pattern for every study, including abdomens, necks, heads, legs, and more. Do you have a specific way you approach each of the sequences on an MRI? This approach is the minimum for starting as a resident on call!

Know When To Get Help

If you are not sure about a finding, what do you do? To answer this question, if you are ready for overnights, you will not blurt out the first idea that comes to your mind. Instead, maybe you will contact the ER physician to get more information or do a google search. Knowing when you don’t know something takes maturity and poise.

Don’t Get Too Shaken By The Mob

It’s always tough when you have a team of tired surgeons hanging on your every word. And they want a STAT read yesterday. Nevertheless, you have the confidence to plow through any case with a stream of eyes and ears watching your every move. They will have to wait until you are ready to give them your impression!

You Know All The More Common Disease Entities And Findings That Will Kill Patients Or Cause Severe Morbidity

If you can make the findings of a patient with diverticulitis, aortic ruptures, bleeds, pneumothoraces, and more, you are more than halfway to your goal of taking call. When taking cases independently, these entities should be on top of your mind. And, you should be actively looking for them when you take any study. Those that do will be unlikely to make any significant misses!

Can Tell Normal Versus Abnormal Fairly Quick

When you have seen enough cases, your brain can tell if an image is normal or abnormal before you can verbalize what the problem might be. You have already trained your brain to know what the general findings of a normal case should be. Therefore, you can look at almost any study and know that you should pursue it further if you assess it as abnormal!

You Make The Findings Before Your CT Attending Does

This one is not a requirement. Nevertheless, it is a good sign. If you can make the findings before your faculty member does, you have already been preparing for the time you would start to take calls. Kudos to you!

Notice A Sigh Of Relief When Your Attending Knows You Are On

Knowing when you are wanted can take a bit of emotional EQ. But, if you notice that your attending’s blood pressure drops by a bit and calms down when you arrive in the morning to work on the day’s rotation, this is generally a good sign. You have your faculty trained to know that you do good work.

You Get Phone Calls From ER Physicians To Ask Your Opinion

You are probably doing a fabulous job if you are getting phone calls asking for you by name because they like your reads. Most ER physicians will not actively seek out a junior radiologist instead of faculty to see what you think. You should be honored that they respect your judgment!

Seasoned Technologists Actively Look For You During The Day

Yes, technologists do know a lot. They most likely have been in the same job for years and have seen many cases. If these folks actively seek you during the day to get your opinion over others, you probably know a thing or two. That’s the ultimate compliment!

Are You Ready To Take Call?

Don’t worry if none of these statements pertain to you early in the year. You still have a bit of time. However, try to make some of these signs your goal before the start of your first call. At that point, you will get the hint that you are ready!

 

 

 

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What Is The Optimal Call Situation For Radiology Residents?

opitmal call situation

Almost every program has its method of giving radiology residents the “call” experience. But, by no means is it standardized. Some programs have in-house attendings to back up the residents. Others use nighthawk, some all the time, and others sparsely. Some don’t have much in-house backup at all. And others weigh CT scans more highly than other modalities. And the list of possibilities for any given program can vary on and on. So, what critical elements of the optimal call situation should you look for when you are thumbing through the different radiology programs out there to find the one that best fits you? Of course, I will give you my two cents!

Independence Of Decision Making For The Optimal Call Situation

First and foremost, unless you want to do research permanently and cannot give a lick about making independent decisions, you should consider this priority one when searching for a call experience. At some point during your residency, you must make your own decisions, which need to count. Without this factor, you will never truly leave your first year of residency. The ability to make sound decisions is the difference between a student and a radiologist. So, make sure you have the power to make some decisions in each of the different modalities. Each modality that you cannot make an independent decision for is one less modality your residency will prepare you for when you finish!

Meaningful Decisions To Have Some Affect On Patient Management

To be clear, making a decision is not enough. The decisions that you make need to have some impact on your workup. The pressure of worrying about patients will keep you up at night, both as a resident and as an attending. Making calls that go nowhere will not be enough to satisfy the requirement of independent call. Every radiologist needs to know the consequences of what we do. Otherwise, you will become powerless to make these same decisions in practice.

A Reasonable Quantity Of Cases

It is easily possible to veer on either side of this equation. Some residencies are so overburdened with cases that the resident has no time to think and make decisions. So, too many of the decisions are bad ones. Likewise, if you are working call at a podunk hospital that is about to close from a lack of patient visits each year, this is not such an optimal call situation for learning either. At nighttime, your residency should have enough work to teach you how to become a radiologist. It’s hard to give you an exact number, but it’s usually a little more than you might think!

A Good Mix Of Cases

Some institutions are in counties where everyone comes from the same culture/background. This mix of cases is not such a great recipe for learning about the diversity of radiology. Also, if the program relegates you to read CT only and gives you no opportunities to look at MRI and plain film cases, this situation will not serve you so well. Find a residency where you can get sufficient studies in all modalities and patients.

Nighthawk Vs. Q Night

Finally, I have always been a proponent of the nighthawk system. I believe it will make your residency life a whole lot better for most of you. I find it very hard to adjust my sleep schedule to the every 4th-day rhythm. On the other hand, your body will get used to the nighthawk sequence reasonably quickly so that you no longer have the 4:30 am blues when you cannot see straight. This factor may not matter much for some with different circadian rhythms. But for me, it makes a humongous difference!

The Optimal Call Situation For Radiology Residents

No call situation is perfect. However, to optimize your overnight learning during your radiology residency, find programs where you have independence and meaning in your decisions, a decent number and mix of cases, and a nighthawk rotation. You will discover that these features will enhance your learning once you practice more independently, which will eventually spill over to your work as an attending. At that point, you will feel comfortable in your skin, knowing that you had excellent training!

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Coping With The Disruptive Study

disruptive study

Ever notice how one or two studies can become the focal point of any night?. Hordes of surgeons, medical specialists, and more come down every fifteen minutes to look at or discuss the case with the radiologist. And, you become the “most popular physician in town.” Sure, it can feel good to be so popular. But, you will find many costs to the disruptive study. On a busy night, you cannot get to the next case. And, the tick-tock of the clock becomes more ominous as the weight of an ungodly list of additional studies piles up. Most critically, you become unable to read everything else. So, how do you prevent a disastrous outcome with unread studies, unhappy doctors, and a nightmarishly long shift? Here are some tips for decreasing the suffering that a disruptive study can cause.

Make Preemptive Phonecalls!

If you know that a case will be “interestingly” positive, make sure to call all the relevant parties beforehand. Although not a guarantee, this polite maneuver will often prevent a group of surgeons or ob/gynecologists from asking you about the case while you are in the middle of dictating something entirely different and complex. Plus, it will make it seem like you are on top of everything.

Don’t Be Ambiguous

Sometimes cases are like magnets to the clinicians because your dictation or what you tell them is not clear. It could be a nodule that you measured as 2 cm in the body of the report, but you stated it was 2 mm in the impression. Or, perhaps, you were not straightforward with your differential diagnosis. Ambiguous reports lead clinicians to find out what is going on by searching for you, especially while dictating something else!

Dictate The Disruptive Study As Quickly As Possible

Cases have a shelf life. If you don’t dictate them on time, the shelf life will end, and you will have a clinician coming down to review the case before you know it, interrupting the workflow for your day. So, as a rule, I try to dictate the “interesting: report as soon as possible. You significantly decrease your colleagues’ chances of stopping you in your tracks.

Tell Your Junior Resident About The Case

Sometimes you are on buddy call or have another radiologist help you out. This opportunity is perfect for teaching your junior resident and then having them go over the case with everyone else! Firstly, this will prepare the resident to learn about a radiological finding or a disease entity. But, it will also teach your junior resident how to go over cases. And the fringe benefit is that you can get the rest of your work done!

Worst Case Scenario- Batten Down The Hatches!

Sometimes the night can get extremely busy. And, you have no time to beat around the bush. As a last resort, sometimes you have to tell the doctors that you are in the middle of doing something else. And that you don’t have the time to go over the study. If you don’t have the time, it’s not cruel to delay a third interpretation of the same case. You do have other cases to read!

The Disruptive Study- Not The End Of The World!

The disruptive study is simply part of our job. Bizarre and challenging cases spark the interest of our colleagues, and they will want to address the issues with you. Nevertheless, we can mitigate the interruptions that it will cause by calling clinicians, increasing clarity, reading cases efficiently, or telling other junior radiologists about them. And worst-case scenario, you can ask them to come back when you are ready. The disruptive study can be painful. But, at least, you have some ways to decrease the potential for it to ruin your whole day!

 

 

 

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Don’t Hesitate To Call Your Colleagues!

call your colleagues

One of the most challenging parts of becoming a radiologist is developing an awareness of when you don’t know something. Of course, when you discover what you are missing, you can look for information on the web to fill in some gaps. But, just as important, it is also critical to know when you need more than your research. Many times, experience alone can teach you the correct diagnosis or management. As a radiologist, I don’t hesitate to pick up the phone if I doubt that I can get the information myself. I call the expert in the subspecialty. So, what are some benefits when you reach out to your colleagues? Well, here are some of the advantages that I have encountered.

Experience Trumps Books Sometimes

Most books only give you some information on how to make a diagnosis. Sometimes, only a vast breadth of experience can help solve some cases. And, if you don’t know, what are the chances you can make that diagnosis? Much less, of course. So, finding someone who can confidently read that temporal bone study can make all the difference in diagnosing a rare congenital disorder. Doing the research yourself is different.

Subtle Management Issues Are Not Easy To Find Online

Many times, you can figure out the patient’s diagnosis, but you can’t find any resources to tell you what to do next. Again, managing a patient’s condition can sometimes only be appropriately triaged when you have made the diagnosis before. So, why not pick up the phone and find the expert who has managed this patient many times? Get it right the first time!

Call Your Colleagues To Increase Confidence In Your Dictations

Other times, you have all the necessary information to make the appropriate recommendations. But what you need is confidence in your report. And it reflects in your dictation. When you speak to an expert colleague, you can confidently diagnose and confirm the next steps. Why not be sure of what you should do next?

Better For Your Learning

When I hear information from someone else, I retain the knowledge more than by looking up a fact in a book or online. Your colleagues will often relay the information on the phone more excitingly so that you can remember the case for a long time. They may give you other examples of similar patients or situations. Or, they lace the information with a good joke! Regardless, sometimes, hearing input from others is the best way to learn.

More Time Efficient To Call Your Colleagues

You can sit around researching information forever or ask someone who has trained for years in the subspecialty and knows a lot. Which one will save you more time? That phone call to your colleague can save valuable minutes of your time and energy. We only have so many hours in a day!

You Will Begin To Get Consults From Others As Well

One of the most exciting parts of becoming a radiologist is getting interesting consults from others. When you ask questions of others, you are also more likely to get consults from your colleagues. They will feel comfortable enough to reach out to you when you have a patient in your subspecialty when they don’t know how to proceed. It’s good to feel needed in your practice!

Don’t Hesitate To Call Your Colleagues!

When you call your colleagues about something you don’t know, you gain experience that you don’t have, learn esoteric management skills, increase confidence, educate yourself, improve time management, and gain the trust of others. So, why not pick up the phone and call your colleague? It is an essential ingredient for excellent patient care!

 

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Don’t Forget To Learn How To Make The Findings!

make the findings

In a few more weeks, most first-year residents will begin to take call and metamorphose from a student into a valuable member of the radiology team. Nightime independent call is what separates the radiology child from the adult. But, as always, most residents have a few hurdles to overcome before they begin. They need to be able to make the findings.

One of the hurdles is the precall quiz—a test before the start of the new year. And, not all first-year residents are ready for the task. Why is that? And what can residents and programs do to equip radiology residents for their newfound role?

Knowledge Versus Search: Two Separate Skills.

Most radiology residents concentrate on the information side of the equation. It’s a much more familiar task. From time and memoriam, including medical school and internship, residents have been studying from books. So, reading books is what they know how to do best. They can remember the names of the disease entities and perhaps some descriptions associated with them. But, radiology is a lot more than recall and picking out a few disease entities from your memory. Instead, it is also the process of making the finding while scrolling through many images on a PACs system. This skill is entirely different. If you don’t believe me, have your average fairly knowledgeable internal medicine physician attempt to read a CT scan and make the findings. It doesn’t tend to work out too well! (There are exceptions to every rule, however!)

How Not To Be Just A Bastion Of Knowledge And Also Make The Findings

Practice

Just like another task in life, you need to put the time in to become proficient—the same works in radiology. You need to spend hours at the workstations scrolling through images in addition to reading the books (as you have been doing for years). If you don’t spend the time with the mouse and the computer on the PACs, your brain will not be ready to pick out the findings when the time comes.

Study Checklists

Whether they admit it or not, every radiologist uses some form of checklist to make sure they have looked at all the parts of the study. And every resident needs to create the same. If you don’t create a checklist, you will never know what is missing. Why? Because residents and non-radiology physicians tend to make positive findings. But, the negative findings can be just as important to figure out history and disposition. Splenectomies, adrenalectomies, and appendectomies are some of the discoveries you will miss on a CT scan if you do not have a checklist for every organ system. And if you miss these, some of your impressions will sound silly or meaningless.,

Look At Pictures

Finally, residents also need to read. And reading differs from the standard physician resident. Internal medicine residents, surgical residents, and ob/GYN residents can get away with reading only the text or reading the text first. But, we radiologists have to do things a bit backward. We need to look at the pictures first, then the captions, and then the text. Why? Because we are an imaging-based specialty, and if we don’t see the findings on an image, we will never know what to find!

Make The Findings!

Remember. Radiologists read a ton because we cross over so many different specialties. But, in the end, we are primarily an imaging specialty. So, we have to learn how to make the findings, not just be an information bank for consultation with our colleagues. Don’t forget to practice a lot by reading lots of films on PACs, utilizing checklists to avoid missing critical findings, and reading the pictures first when reading textbooks. Practicing these skills will enable you to become an excellent radiology resident and a great radiologist. It’s not all about just reading books!

 

 

 

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Passed The Radexam Precall Quiz? You May Still Not Be Ready To Take Call!

radexam precall quiz

Ask ten different program directors on how they decide if their residents are ready to take calls and place them in the same room. You will most likely get ten different answers, plus a heated debate (maybe a fistfight or two!) But, I have witnessed some residents who have passed the Radexam precall quiz perform poorly on call. Likewise, I have seen residents with borderline or failing scores on Radexam make a stellar performance when they start overnights. So, what is it that the exam is missing? I think I have it all figured out!

When we look at the skills that you need to succeed at nighttime, there are three general categories: reading, picking up findings, and professionalism. The Radexam tests the first part, knowledge, and I believe it is acceptable for this purpose. But, it leaves out the other two essential categories. Fortunately, most residents are professional, and you can observe their professionalism during their first year, so that category is not usually difficult to assess. However, the ability to pick up findings is a whole other kettle of fish. Some residents can have a vast knowledge base, yet have a tough time making the calls on a film. If you don’t test for it or observe it, you may miss these prospective call-takers. Houston, there may be a problem!

What Can You Do To Improve Your Finding Skills?

If you think you might be in this boat, what can you do to improve your finding skills? Well, several different techniques can help to improve your skills. The first and most obvious way to improve this skill is to read through lots of cases without knowing the answer beforehand. In today’s environment, in some programs, it is effortless for some residents to slide by without having to make any decisions on their own during the first year. These residents will typically either sit by the attending and watch them make all the findings. Or, they will continue to read books during the day without being an active participant in the case. If you want to learn the skill of making findings, passive learning techniques such as these don’t cut it. You need to flip through the cases on your own!

Additionally, you need to use materials that use lots of images. Now, this is a widespread first-year mistake. Many first-year residents continue to study like interns and read lots of materials without looking at the pictures. In radiology, you need to do the opposite. You need to look at lots of pictures and then read the content. To find appendicitis, you should see at least a hundred different cases before you can readily identify it. Some instances are subtle, and others not so much. Looking at all different sorts of examples of a particular disease entity will eventually get you to the point where you can easily make the findings without as much mental effort.

And finally, there is a subgroup of residents who have not read one lick during their first year. If you don’t know what the different disease entities are, how will you find them? However, this group overlaps with the lack of professionalism and lack of knowledge groups. Most residency directors can pick these folks out. And then, it’s a natural remedy. Read more!

How Should Program Directors Test For This Skill?

Direct observation is the key. Just utilizing a test like Radexam only tests the knowledge component and cannot substitute for observing a resident taking real cases.

Now, at some programs, the faculty may not have much time. But that is not an excuse. Testing residents before overnights is the moral and ethical thing to do. How can you allow a resident without the proper tools to take care of patients? It is unjustifiable!

To test residents for finding skills, I typically take a series of 10 reasonable overnight sorts of cases and watch how they perform when looking for the findings. Usually, I make sure that the residents can get about 2/3 of them right. I’m sure there are other ways to do the same thing, but I have found it reasonably simple to find a group of typical on-call cases.

Also, in the real world, you do not have the luxury of infinite time. So, we make sure to limit the amount of time per case. This simple process can quickly identify residents that are falling off the bell curve because they take to long to look at a case.

Are You Ready To Take Call After Passing The Radexam Precall Quiz?

Well, for those of you that are finishing up their first year, right about now, make sure that you continue to go through cases even after taking the Radexam Precall Quiz. If you don’t have a formal method to check whether you are ready in your residency, please make sure to ask your faculty or a senior resident to observe you. Sometimes you need a second set of eyes to ensure you are on the right path. If you want to get an idea of some of the cases for testing in our residency program, I will refer you to the previous years’ pre-call quizzes on this website for a nominal fee. Check them out! Otherwise, make sure to go through your institution’s classic cases without knowing the diagnoses beforehand. This process works to make you a better on-call radiologist!

 

 

 

 

 

 

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Final Results From The Radiology Call Pain Points Poll!

pain points

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Radiology Pain Points Survey Results

The results of the radiology pain points survey are finally in. And, I bet that many of you would like to know if your colleagues have the same feelings of dread about overnights as you do. So, let’s get right down to the nitty-gritty.

Of all the most dreaded parts of the overnight call, a majority of the respondents stated that they dreaded missing findings the most (51%). And, that makes sense given that everyone has the potential to miss something critical in the wee hours. In second place (30%), you guys selected lack of sleep. Again, not surprising because most of us hate the feeling of nausea and dizziness that sets in at 4 AM. Our bodies and mind abhor lack of sleep! In a distant third (8%), you had selected the fear of injuring patients as the most dreaded aspect of overnights. I had expected this fear to be a little bit higher. But, missing findings often lead to patient injury. So, perhaps this is the proximate cause for this response. And, therefore, you picked this response less frequently.

And finally, there was a smattering of other responses, including a confrontation with colleagues, and some great comments like -dealing with phone calls, contrast reactions, and the isolation of overnights.

Take-Home Message

So, what is the final take-home message from this poll? Well, for one, we need to come up with better ways for you to deal with some of the most significant issues that you will face on overnight call. I don’t believe many residencies have addressed these issues well. For example, we talk about sleep deprivation, and most residencies give you some lectures at the beginning of the academic year. But, what are some real-world radiology specific techniques that we can utilize to mitigate its effects? And, how can we ensure that you have the tools to make the necessary findings at nighttime? Are a precall quiz and a first-year introducti0n to call enough? Perhaps, residencies and the regulating bodies need to do more. Just some food for thought!

 

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How Do I Know Which Cases To Discuss With My Attending In The Morning?

You’ve made it through a typical night of call and the attending for the day is about to arrive. Your mind begins to meltdown from the exhaustion of it all. And, there are too many cases to discuss with your morning radiologist. It’s just going to take too long.

Moreover, you don’t want to waste your attending’s time with the obvious. On the other hand, you are not sure about what you are going to have missed during your shift. And, you want to make sure that you address all the critical issues. So, how do you go about deciding which cases to discuss with your morning attending? And what can you ignore? To increase your efficiency, let’s go over some of the basic guidelines.

All Cases That Can Significantly Change Patient Medical Management

Remember, in the end, every case that you sign off at nighttime, also will have your attending’s name on it too. By default, therefore, you should show every situation to your attending that will significantly change medical management. Now, what exactly does that mean? If your patient has gone to surgery based on your findings for any reason, that would certainly qualify. Or, if the patient needs to stay overnight because of your call, that would be eligible too.

In essence, I would have a low threshold for what constitutes a change in patient management. And, if it meets that criteria, well then, you must show it!

Equivocal Findings

It’s those cases that you hem and haw over. These are the best learning tools. So, make the most of them. Even it’s not the most clinically significant case; I would highly recommend that you try to discuss it with your morning attending. It’s one way that you may never discover that finding to be equivocal again. Think about all that time over your career that you will waste that you could have figured out immediately by just asking your attendings in the morning. Why wouldn’t you bother to do that?

Discrepant Reports With The Nighthawk

If you want to get burned, the best way to do it: Don’t go over discrepant nighthawk reports with your attending. I have been on the receiving end of one or two of these unmitigated disasters. And, the resident could have avoided it by simply telling me about it.

Moreover, even if the resident gets it right, and the nighthawk misses the case, it can still become a problem. Medically, the emergency physician can administer the wrong medication based on the nighthawk read. Or even potentially worse, she may not administer treatment based on his final report. Therefore, please let your attending know about these cases, especially if you made the critical finding, and the nighthawk reader missed the obvious!

Discrepant Reports With The Emergency Physician

Just as often as nighthawk discrepancies, if you forget to go over those cases where your opinion differs from the ED physician, you are potentially asking for trouble. Immediately, these cases should be some of the first that you must discuss in the morning. In addition to increasing the work burden on your morning reader, your attending will likely have to make a whole bunch of unnecessary phone calls if he doesn’t know that there was a discrepancy.  Your goal should be to reduce the amount of work your attending needs to complete, not increase it!

Any Other Cases With Questions

Sometimes, cases bring up fascinating points or other medical management questions. And, what better time to ask questions to reinforce what you have learned at nighttime? After residency, you will not have these opportune moments again. So, take advantage of making inquiries with experts while you can!

Whew, That’s A Lot Of Cases To Discuss!

Well, not necessarily. It sounds like a lot more than it is.  Often, these cases are the minority of what you will experience at nighttime. And, fortunately, most nights, you will encounter many normals and garden variety cases that don’t need to take up a lot of your time in the morning. However, regardless of the number of cases, it always pays to go over those cases that need extra attention and care, whether it’s for medical management issues, equivocal findings, discrepancies, or simple questions. It’s a fantastic tool for learning, and more critically, a moral duty for excellent patient care!

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Should I Waste Time Looking For Tiny Lung Nodules At Nighttime?

lung nodules

One of my former residency mentors said the following as he proudly scrolled through the electric film panel reader without stopping as he dictated, “You can miss em’ fast, or you can miss em’ slow!”

And, the life of a resident works non-stop, just like this former radiologist, especially on a busy night of call during residency. At least at our institution, we can easily have a night of 40-50 CT scans, 10 MRIs, 20 ultrasounds, multiple plain films, and fluoroscopy consults. Even though it’s tough, we expect our residents to churn through all these images and more! Then finally, in addition to all of this, we require them to dictate the cases that they’ve previewed.

So, with all this work that the typical resident needs to complete on an average night, does it make sense to worry about every little detail? I mean, how bad can it be to miss a 2 mm lung nodule or a 3 mm hepatic cyst or hemangioma? Well, I don’t like to be dogmatic about what’s right before I review the evidence. So, let’s consider the pros and cons of what it means to skip the imaging details.

Pros Of Missing The Tiny Lung Nodules

So, let’s start with talking about why we can forgive our residents for missing a few lung nodules here and there. Well, who cares if the resident flies past a few nodules at nighttime, as long as she has picked up the big stuff, yes? If you pick up a pseudoaneurysm of the common femoral artery and you miss a renal cyst, you’ve done your job. You’ve prevented severe harm and injury to the patient. What more could a residency director ask?

Moreover, the attending usually picks up the other findings in the morning that the resident misses. Regardless of whatever the covering radiologist does, she can always count on the backup of another set of eyes.

Also, if you are so busy at nighttime searching for nodules and cysts, how will you have time to look through all the other cases as well. Indeed, it is not critical to find that next nodule, when you need to get to that next case that can potentially have free air and pneumatosis.

And lastly, what is the harm to the patient of missing the incidental small lung nodule? Well, that is also close to zero, right?

Cons About Skipping The Small Stuff

But wait, is that all? Can we miss these nodules with impunity? Stop there.

Do you want to become a fully-trained radiologist? A well-heeled radiologist will never skip looking for any of the potentially relevant findings. They will always look for all the nodules and cysts on a CT scan. By practicing forgetting to search for these nodules, you are encouraging yourself to miss the same findings when you complete your residency. If you want to become a great radiologist, you need to act one early on.

Additionally, not all small stuff is harmless. Occasionally, those 3 mm nodules turn into that 4 cm mass which happens to be lung cancer. I’ve seen that happen with my own two eyes frequently, having interpreted multiple rare cases for a contract research organization that had us read cases for numerous drug trials. The risks are real, albeit small.

And, finally, not all the nodules and cysts are picked up by the morning radiologist. Just like anyone else in any profession, we cannot be perfect. If you did not make these findings at nighttime, how do you know that the morning radiologist has also picked it up as well?

For And Against- Where Should You Lie?

Both camps have some excellent points to make. And, stepping back from the fray, they can both make some sense. However, I would argue that you need to make your judgments about what to do.

Of course, if you are having an insane night with busloads of patients getting scanned, you need to triage your reads. Getting through all the cases trumps the potential for missing a lung nodule.

On the other hand, on a reasonable night, why not look for all the findings? You are doing an extra service to the patient and the morning’s radiologist. And, just as critically, you are augmenting your radiological skills.

Nodules or no nodules, one of the essential skills a resident should pick up from their residency is learning the art of sound judgment. We should leave this task to you to help you grow as a radiologist. Every time we allow, you, the resident, to make up your mind, and see the consequences, you learn a bit more. And, that’s the point of nighttime call for a radiology resident, to decide to look for tiny nodules or not.  Let’s not forget that!