Tag: nighttime

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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!

 

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Dealing With The Abusive Nighttime Physician: Rules Of The Road

abusive

Picture this scenario. A Napoleon-like 5 foot 2 verbally abusive surgeon enters the reading room. He begins to yell at you for not performing an intussusception reduction the way he likes. Moreover, a team of surgical residents stand behind him, each member turning red with embarrassment as he continues with his tirade. His verbal abusiveness becomes more and more aggressive. He uses terms such as “idiot” and “moron” to describe you as you attempt to get a word in edgewise. You feel like you want to strike your fist in his face. Does this situation sound vaguely familiar? How would you deal with this everyday but unfortunate situation when you are alone at nighttime?

#MeToo

First, no one should have to contend with harassment such as this. I don’t care if you are a resident, nurse, janitor, or attending. Unfortunately, although society has finally come to terms with refusing such abusive behavior and isolating these individuals, many hospitals still silently condone it. How and why? Perhaps, the hospital is understaffed and would rather have someone to fill the gaps even though he has an abusive personality. Or, the hospital may hire an inappropriate physician because she has a good reputation and brings many patients into the system. Regardless, the behavior is unacceptable and needs to be dealt with accordingly. So, let’s go through some of the processes you need to complete to prevent this harassment again.

Engage Softly With Team Response

The last thing you want to do as a resident is fight fire with fire. If you continue to raise your voice and tussle with this attending, you are making a containable situation into a nuclear bomb! Instead, what is the appropriate course of action?

You can say to this individual quietly, “I am just trying to help you care for your patients appropriately. We are in this together. I will talk to you again when you speak to me professionally so we can help your patient together.” Usually, the raving physician calms down if you maintain a quiet and calm demeanor. At this point, the situation usually de-escalates. Who knows? You may even receive an apology. But that may or may not be the case.

Document, Document, Document

So, what next, assuming the situation does not calm down? If the surgeon has been harassing you, it is most likely a long-standing observable pattern of inappropriate behavior. And this physician has likely affected many other employees within the hospital as well. Therefore, you should document the behavior in written form. State the time, place, and situation as objectively as you can. Then, place the document on the side for further use, if necessary.

Next, you may want to ask other observers, if present, to create a supporting document. This report lends credence to your inappropriate interaction. You are better off gathering multiple documents to establish a pattern of behavior.

And finally, for each time you encounter these behaviors with this individual, you create another document. You are making a paper trail that will help remedy this situation.

Speak To Your Supervisor

As for the next step, you must contact your residency director or associate residency director first thing in the morning. Speak to them and give them the documentation. If possible, leave the wheeling and dealing in the hands of the local administration. Why? Well, often, the lowly resident does not have the influence upon human resources or senior administration like a long-standing faculty member does. And, the administration can turn back the blame on you.

Last Resort- Human Resources

OK. So, your supervisor has not yet fixed the situation. Or, maybe she settled it for that one time, but the abuse is recurrent. Where do you go next? Sometimes you have to go right for the horse’s mouth. You may need to talk directly to human resources and hand in the documentation yourself. Usually, this will begin a full investigation into the matter. Of course, hopefully, you can avoid this situation. Unfortunately, on occasion, you need to act to protect yourself in this way.

Final Thoughts About The Abusive Physician

We all went to medical school and began training to become consummate professionals. Along the way, unfortunately, you will encounter abusive physicians that do not follow these rules of professionalism. Often they have issues of their own. But that does not excuse the actions of these individuals. We, as clinicians, should act according to the rules of civil behavior. And if these abusive physicians cannot play by the rules, either they need to change their ways, or they should not be able to practice medicine. So, we serve all by taking action and not remaining silent.

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When To Say No At Nighttime (A Resident Guide)

no at nighttime

Radiology residents can expect disagreement with a nurse, fellow resident, or attending on any given night. Due to lack of sleep, tempers flare, and we magnify minor problems into large ones. Ultimately, we mostly accommodate our colleagues and perform the study they request as we should! Sometimes, however, saying no at nighttime can be one of the most important yet challenging responsibilities of a radiologist on call that we need to learn. We don’t want to offend our colleagues’ sensibilities or upset the attendings of other clinical services. And we want to ensure that we complete studies promptly to increase ER turnover. Yet, there is a time in all radiologists’ careers when the right thing to do is say no.

But, at what point should you say no, I won’t comply with your request? Let’s explore this issue of when to say no at nighttime. We will discuss some of the most common circumstances for the radiologist to refuse a request appropriately. For each case, we will discuss how you should proceed instead.

Studies That Would Cause Undue Patient Risks

Out of all the reasons to refuse a study, most importantly, we must ensure that we comply with the Hippocratic oath, “First do no harm.” This oath is priority number one. For all of us, a time will come when a resident or attending will ask us to perform a study or procedure that can potentially harm the patient. It could be an unnecessary CT scan on a pregnant woman or a biopsy on a patient with an elevated INR. As a physician, we need to prevent these procedures from getting completed. It is our first and foremost responsibility.

So, how do we stop a study when attendings or residents apply crushing pressure to perform the exam? First, we need to elaborate on the data behind why such a study would harm the patient. And then, most importantly, we need to do it in a way that does not demean or upset the physician. This technique is where the art and science of medicine meet in the middle.

Procedures That Would Jeopardize Your Safety

Not only do we have a responsibility to our patients. But also, we have a responsibility to maintain our safety. To take care of others, one must take care of oneself. So, to put yourself in significant danger, simply put, clearly does not meet the sniff test of practicing good medicine. The test could involve putting yourself in harm’s way with a combative patient or exposing yourself to undue radiation. Make sure to think about your situation first before going ahead.

How do you decide if the procedure would affect your safety for you to say no at nighttime? Always think about the potential consequences of a worst-case scenario. If you can think of a situation when you can get seriously injured from a study, it is probably not the best idea to complete the procedure.

Interpretations Or Procedures That Need An Attending

Sometimes we should not complete a test or procedure unless an attending can be present. You may be able to perform the exam adeptly. But, it is not in your best interest to complete the study for legal or ethical reasons.

How do you judge if the study may not qualify as a resident’s domain? If the procedure can result in significant harm unless performed by the appropriate personnel or a protocol establishes that a resident should not complete the study, hold off and call your attending. Let’s give you an example, such as a brain death study. Although easily interpreted by a resident many times, the consequences of “missing” can result in severe harm. Additionally, many programs have protocols for attendings to read this examination.

Inadequate Resources

This one may seem pretty obvious. However, we should not promise to complete a test if we don’t have the capability of finishing it. Often, residents unknowingly will offer a solution to a problem that may not exist in your institution. Or the institution cannot obtain the resources on the night of your call. For instance, you may promise the clinician that you can perform a V/Q scan, not realizing that the agents are in short supply. Unfortunately, this disrupts management, the timing of testing, and the formation of a patient’s final disposition. So, always make sure to check that you can complete a test before you allow the order. And, make sure to let the ordering doc know!

Nondiagnostic Studies

Occasionally, you find an adamant clinician or resident who demands the immediate performance of a test that will not assist in making a diagnosis. In a huff, these folks can propel you down the wrong road. In this situation, it pays to push back a bit. How? Data is your friend. Perhaps, the clinician insists they need a bleeding scan when the patient has a very slow bleed. Calmly, you need to explain why the test would not change the patient’s situation or add any additional significant information. Usually, the ordering physician will comply.

Things That Take Up Too Much of Your Time At the Expense of Patient Care

Often, students, residents, or even faculty will ask for assistance on all sorts of studies they may need help interpreting. However, your time can be minimal. A typical example: A resident asks for a reinterpretation of a cancer workup performed six months ago. Now, it may be essential to perform at some point. But, if you have 20 trauma cases that you still have not read, is it the correct decision to look at this sort of study? Probably not. So, politely tell the resident your situation. Trust me. This physician will go away and let you interpret your STAT cases.

Repeating Similar Previous Studies Without Good Reason

Finally, it is not uncommon to find orders for a repeat CT scan or fluoroscopic study after someone has recently performed it. Clinicians sometimes make errors in unknowingly repeating studies. I can’t tell you how many times this has happened. As radiologists, we are responsible for checking and finding out if these studies are indeed warranted. Again, you must calmly and politely let the ordering clinician know if this is the case.

Final Thoughts About Saying No At Nighttime

Saying no can take real guts when you are not the “authority.” But, when to say no at nighttime needs to be learned by all residents. It can be an art as well as a science. And the lessons stay with you for the rest of your career. So, if the situation arises that you need to say no at nighttime and it can affect patient care, respond gently and with the data to prove your point. The rewards of saying no can be immense.

 

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

night float

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 keep on streaming in. These feelings were typical on that first night of call on a 1 or 2 weeknight 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 many radiology residency programs. It is almost impossible not to have at least a few overnight shifts like the ones I just described.

At one point or another, many radiology programs and residents have come up with different schedules and options 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. Programs have many considerations before deciding to have either of these systems before implementation. Although I tend to favor the night float system since I remember it mitigated fatigue after the initial day or two of calls when taking overnights, the decision to have a night float program is probably unsuitable for all programs.

So what factors would lead one program to have a night float system and another to have a standard call system? Some of the issues we need to address are the size of the program, attending coverage, resident preferences, program director preferences/department culture, number of nighttime studies, and emergency department requests. I will also review each system’s disadvantages and advantages, allowing a program to decide which approach is best.

Factors For Instituting A Night Float Coverage System

 

Size of the Program

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

Attending Coverage

Institutions with attending nighthawk coverage at nighttime allow more flexibility for scheduling of night float. Some programs do not need full-time resident coverage during the nights and may share call obligations with the attending. 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 because of the preferences of the individual residents. Many residents have fully invested in a given scenario. If the system is changed, there is a perception of “unfairness” because some residents may need to take more or fewer calls than they would have in the old system. So, the night coverage system becomes engrained into the fabric of the residency program.

Also, the program director may set up this schedule to accommodate specific residency daytime programs. A nighttime schedule may allow the resident to maximize daytime educational opportunities. For 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

In many programs, the leaders may institute nighttime coverage based on their preferences. The program director or chairperson may believe a night float system or standard call schedule may be better for a residency program. Or, perhaps there are coverage requirements that the department desires. In either case, the decision is not up to the residents.

Number of Studies

Perhaps you are in a residency program that is a level 1 trauma center with significant numbers of ER studies at night time. Some programs are so busy that they may need more than one resident or attending on-call each evening. This factor may allow less flexibility in scheduling 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 radiology coverage at nighttime. Some programs may only want to have senior residents take call. Others specifically want attendings to cover during the evening. 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 reflect the whims of the emergency department.

 

Advantages/Disadvantages of Night Float And Standard Call

Night float

Most people think night float coverage for a week or two mitigates fatigue the most. The body tends to get used to the nighttime schedule over time, allowing the resident to function better on call. Sure, the first few days can be challenging 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 lose touch with the “educational” aspects of the residency program. You miss daytime lectures, conferences, and attending readouts for long periods. While the time spent on night float is essential for training, receiving all the benefits of daytime resident education is impossible. You may lose out on understanding the context of the images you interpret. 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, allowing the resident a better overall experience. The resident does not miss all the noon conferences and educational experiences they would miss over a long block on a night float.

The two significant disadvantages to the cyclical call schedule are overnight fatigue and the “lost day.” As I mentioned, 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, just like most residents. In addition, the resident loses an extra day of residency experience every time they work because they are obligated to have a day off afterward, “the post-call day.” This loss can significantly decrease the educational opportunities for the resident.

 

Residency Call- Night Float or Overnight Calls?

Nighttime call is a crucial 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 method can be complex, but it is important to weigh each of the factors to come up with an outcome. The key is to make the learning opportunity pleasant and mitigate fatigue. Hopefully, your residency has chosen your institution’s most appropriate night coverage system!