Midwest Surgical Association Impact on patient care of discordance in radiology readings between external overnight radiology services and staff radiology readings at a level 1 trauma center

Abstract BACKGROUND: Overnight radiology services (ORSs) provide computed tomography (CT) scan readings that are automatically reviewed by staff radiologists (SRs) and the trauma service. Discordant readings and their clinical significance were investigated. METHODS: ORS-read CT scans over 3 years were reviewed. A discordant reading was clinically significant if it resulted in a substantive change in patient care. All clinically significant findings were reviewed by a blinded radiologist. RESULTS: Five hundred thirty-four CT scans were identified: 191 (35.8%) head, 187 (35%) cervical, 66 (12.4%) chest, and 90 (16.9%) abdomen/pelvis scans. One hundred twenty-three scans (23%) were abnormal with a DR of 16%: 5 head, 2 cervical, 7 chest, and 6 abdomen/pelvis scans. Seven (6%) scans had clinically significant findings missed: 3 head and 4 abdomen/pelvis scans. ORSs missed 7, and SRs missed 3 clinically significant findings. A blinded radiologist confirmed the clinically significant findings. CONCLUSIONS: The discordant rate of readings for abnormal CT scans was 16% with 37% considered to be clinically significant. ORSs missed 100%, and 29% of the clinically significant findings were identified after SR/trauma service rounds. SR/trauma service review of ORS readings is supported. Ó 2013 Elsevier Inc. All rights reserved. Since the 1990s, teleradiology services have been used by many emergency departments to provide preliminary interpretations on diagnostic images including computed tomography (CT) scans, x-rays, and magnetic resonance imaging (MRI) for overnight emergency and trauma patients. With US-licensed radiologists stationed throughout the nation and overseas, these teleradiology firms were able to maximize the time zone difference and provide 24/7 coverage to many institutions. Their ability to provide overnight coverage, or ''nighthawking,'' was their main appeal. They rapidly became the solution for many hospitals struggling with the economic burden of staffing an overnight shift with potentially sleep-deprived radiologists. These teleradiology firms currently provide overnight coverage for more than 1,500 US emergency departments. 1 Despite their popularity, there are no studies comparing the error rate of preliminary readings of external overnight radiology services (ORSs) with in-house attendin

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

Purpose: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Method: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. Results: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Conclusions: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

Purpose: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Method: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. Results: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Conclusions: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior

Assessing the 16 Hour Intern Shift Limit: Results of a Multi-Center, Mixed-Methods Study of Residents and Faculty in General Surgery

Background The study explores how residents and faculty assess the ACGME\u27s 16-h limit on intern shifts. Methods Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. Results Few view the intern shift limit as a positive change. Views differ (P \u3c 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. Conclusions The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty

The Promise and Problems of Non-Physician Practitioners in General Surgery Education: Results of a Multi-Center, Mixed-Methods Study of Faculty

Background Nurse Practitioners and Physician Assistants – called non-physician practitioners or NPPs – are common, but little is known about their educational promise and problems. Methods General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. Results NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. Conclusions NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes

Assessing the 16 Hour Intern Shift Limit: Results of a Multi-Center, Mixed-Methods Study of Residents and Faculty in General Surgery

Background The study explores how residents and faculty assess the ACGME\u27s 16-h limit on intern shifts. Methods Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. Results Few view the intern shift limit as a positive change. Views differ (P \u3c 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. Conclusions The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty

The Promise and Problems of Non-Physician Practitioners in General Surgery Education: Results of a Multi-Center, Mixed-Methods Study of Faculty

Background Nurse Practitioners and Physician Assistants – called non-physician practitioners or NPPs – are common, but little is known about their educational promise and problems. Methods General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. Results NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. Conclusions NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes

The Promise and Problems of Non-Physician Practitioners in General Surgery Education: Results of a Multi-Center, Mixed-Methods Study of Faculty

Background Nurse Practitioners and Physician Assistants – called non-physician practitioners or NPPs – are common, but little is known about their educational promise and problems. Methods General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. Results NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. Conclusions NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes