We chatted with Joseph G. Mammarappallil M.D., Ph.D. a diagnostic radiologist at Wake Forest Baptist Health (WakeMed) in Winston-Salem, North Carolina, about the expectations, workload, and challenges that residents face when on-call.
“Several studies at our hospital say that our turnaround time plays a significant role in length of patient stay,” said Dr. Mammarappallil. With evidence like this, it’s no wonder on-call residents are facing increased pressure from the ED to deliver reports faster than ever. While this may not be a trend for every hospital, it rings true of academic hospitals that are increasing the size of their network.
A number of academic hospitals like WakeMed are growing their network and buying up small, neighboring hospitals. As a result, the radiology department is absorbing the additional studies and the on-callers are shouldering more of the workload. However, as with almost every hospital around the country, the size of WakeMed’s residency program has remained the same.
"The addition of a moonlighting senior resident to read studies during high volume times has helped balance the workload, though,” said Dr. Mammarappallil.
Back in the day the term “wet read” was used for emergent or critical findings so that radiologists could deliver the detailed findings later (while the x-rays were still processing in chemical tanks). But like Bob Dylan sang, “the times, they are a-changing.” Now there is pressure from the ED to have full dictated reports included in that fast turnaround time. “It’s not just quantity—it’s also the quality of the reports [that have increased], especially in the inpatient setting,” said Dr. Mammarappallil. “If you get sloughed down on the inpatient studies and it takes you an hour and a half, then you are that much farther behind on the ED studies.”
As networks grow, hospitals like WakeMed are handling trauma and other critically ill transfer patients that smaller hospitals can’t undertake. Although these patients come with full imaging sets, occasionally with reports from a nighthawk service, the grand majority of the time they don’t come with dictations. As a result, on-callers have to put dictations on these studies or review them with the accepting clinical team.
“There is increasing pressure by academic centers to get attending physicians in-house at least until midnight so that final reports can be turned around to the ED. Even if diagnostic radiologists deliver a full dictation, a lot of places want finalized reports as part of the turnaround, very quickly,” said Dr. Mammarappallil. Although this hasn’t come to fruition at WakeMed, it’s becoming a trend across the country to bring board-certified radiologists in house.Dr. Mammarappallil is quick to point out the strength of the WakeMed radiology program—the residents. “We are a resident-run program. We read everything from 5 p.m. until 7 a.m. without an attending looking at it, so you’re kind of under pressure to make a call, and it makes you a better radiologist.”
While some academic hospital residency programs might be facing an increased workload, program curriculum is astutely aimed at balancing this workload and addressing related worries before they become problems. Program directors regularly meet with residents to present ways to manage stress and keep professional matters from detracting from personal and family time. Fitness, diet and sleep are top priorities. “Stress level and time off from radiology are a big deal to our program director,” said Dr. Mammarappallil.
Most of all, community is emphasized. “We have a good call system. Even on that stressful 5 p.m. -11 p.m. shift there are peers available to evaluate the same study with you.”