New research reveals that well-trained residents can read studies after hours with no clinically significant negative outcome for the patient.

Each new generation of radiologists must be trained to read images, but to really develop these skills requires reading many exams. Training can—and often does—occur "on the job," independently but with supervision, which benefits the education process. However, educators must balance those needs with the needs of the patient, who should be given the best care possible.

New research shows that well-trained residents can competently read studies after hours with no clinically significant negative outcome for the patient. Physicians and educators can therefore be confident with programs that take this approach. "We want to safely educate [residents] on the front lines and have them take care of patients without putting the patients at risk," said Richard B. Ruchman, MD, chief of radiology and director of the radiology residency program at Monmouth Medical Center in Long Branch, NJ.

Ruchman spearheaded the study, which appeared in the American Journal of Roentgenology* in September 2007. (For details, see Ruchman RD, Jaeger J, Wiggins EF III, et al. Preliminary radiology resident interpretations versus final attending radiologist interpretations and the impact on patient care in a community hospital. (AJR Am J Roentgenol. 2007;189:523-526.)

At Monmouth, the residency program is continuously measuring quality and tracking the accuracy of residency reports given to physicians. In 2001, the team began collecting data related to on-call resident reading. "[During the on-call shift] residents would write down their findings. In the morning, the attendings would review the studies and look for discrepancies. When appropriate, reports were corrected and resubmitted to the referring physicians," said Ruchman.

When the stats were analyzed 3 years later to examine safety, data on nearly 12,000 cases had been gathered—every study ordered after hours. "No study previously had covered the volume or breadth of imaging exams," said Ruchman.

Discrepancies were defined as major or minor. Major discrepancies had the potential to significantly impact patient care, often requiring verbal notice to the referring physician; minor ones were judged to have no direct impact. Ruchman illustrates by comparing a missed diagnosis of appendicitis (major) against a simple renal cyst (minor). Professionals from the general medicine department determined clinical impact based on charts to help categorize discrepancies without bias.

Data analysis found a major discrepancy rate of 2.62% and a minor rate of 21.37%. Ruchman compares this to the attending misinterpretation rate of 2.1% to indicate that residents do not perform significantly worse than attendings. The most major discrepancies involved abdominal and chest examinations. The most commonly missed diagnoses were acute appendicitis followed by pulmonary embolism. Ruchman attributes this to the nature of the exams.

"These are very subtle diagnoses. In the case of appendicitis, physicians are looking for a tiny structure in the mass of bowel," said Ruchman. The study found 81% of discrepancies related to appendicitis were false negatives and suggests that may be due to "inherent limitations based on the quality of the examination and the presence of equivocal findings."

But these cases had few clinically significant medical consequences. A significant negative clinical effect was found in 0.3%. The researchers therefore concluded that there "is no detrimental effect on the quality of patient care from relying on preliminary interpretation made by radiology residents."

This fact was found to hold true for properly trained first-year residents as well. Monmouth's residents must complete a battery of tests before they are able to take call. The Accreditation Council for Graduate Medical Education (ACGME of Chicago) currently mandates that only second-year residents and older can read films. "But we found that first-year residents, who were well trained and supervised, could read properly. This supports a change in the rules," noted Ruchman.

Whether a change in the rules is effected or not, Ruchman points out that what is important about the study is that for hospitals in which there is a radiology residency, referring physicians can have confidence in a well-trained resident.

—Renee DiIulio