After Hours Radiology: Substandard Readings?

Is the radiology department changing its mind after your patient is discharged?

Radiology discrepancies, errors made by emergency physicians on our preliminary readings, are a part of practicing emergency medicine. After all, we aren’t the experts (so they tell us). Either way, it is nice to have a safety net of residency-trained board-certified radiologists to back us up, providing us with a formal and “final” reading. Unfortunately, our radiology colleagues tore a big hole in this safety net several years ago when they began outsourcing their work.

It was not all that long ago that the radiologist, your colleague, was available 24/7 if you needed them for an unusual plain film consult, or more often for a final reading on a special study (i.e. CT, ultrasound, etc.). Now, they are only available during the day. Perhaps they got tired of coming in to read at night or of working night shifts and staying at the hospital. First, they went with teleradiography. I get it; if you can read the studies at home in your boxers, go for it, as long as the patients get a timely, quality interpretation. As I recall, this lasted about five years before they transitioned to the use of after hours services which made it so that radiologists didn’t have to read any studies at night. I’m still kind of OK with that. It’s your specialty and your money. If you want to pay some other radiologist to do your work or give up billable studies to another group, that’s your call. All things equal, as long as we are getting the same service, I really don’t care.

When I do mind is when patient care suffers. My experience with after hours services is that the quality is less than that of local radiologists and two standards of care have evolved: day time care and substandard care at night. It is unconscionable to me that any physician would accept a lesser quality of care to improve their work schedule. I know, many may say that they don’t believe the quality is any less with after hours services as it is with their own radiologists. Well, I’d agree with you if it weren’t for the advent of the CT preliminary reading.

If the radiologist is the expert and the quality is the same both night and day, why is it that most radiology departments reread after hours studies the next day, and why is it that the readings from many of these services are titled, “Preliminary reading”? There is only one reason: even the radiologists know that the quality isn’t the same. Remember, we are talking about special studies here. The stakes are high. The potential misses are much more substantial than most of those missed on plain films.

I have spoken to hundreds of physicians about this topic and all report seeing an increase in radiology misses on CT scans, ultrasounds, etc… Tracking this from a quality assurance perspective, the most common that we are seeing are cases of missed appendicitis. However, missed strokes, subdural hematomas, other intracranial hemorrhages and pulmonary emboli are not infrequent occurrences. 

This practice substantially increases the risk to our patients, the individual emergency physician, their group and the hospital. Once the “expert” has provided their reading on these studies, we rely and act on them. So, these patients are often discharged only to be called the next day and asked to return. Some return. Some have gone elsewhere, and some, well you don’t want to know.

So, how big of a problem is this? Ask your friends and partners. Everyone has a story. From an internal survey of 150 emergency physicians that I conducted, 73% reported that they had been contacted by radiology to change a reading on a special study, with CT being the most common. Those 73% were asked how many times this happened to them in the past twelve months. 21% reported one occurrence. 50% reported this occurred 2-5 times. 18% reported 5-10 times, and 11% reported more than 10 occurrences annually.

If you still aren’t convinced, the same physicians were asked if patient management was ever changed by these “reverse radiology discrepancies.” 86% reported that such changes in reading did, in fact, alter the patient’s management. Changes in management were qualified as actual changes in the plan of care – more than simply a phone call and a chart addendum. Perhaps of greatest concern is that 13% of respondents reported that a change in radiology reading resulted in a bad outcome. Bad outcomes were qualified as complications due to delays in management, including prolonged hospitalizations and even deaths.

Unfortunately, we don’t control this decision or this process. However, we do have first hand knowledge of the potential quality concerns with using after hours radiology services. We need to be vocal with our radiology departments, advising them of our discontent with this process, demanding improved performance when clear examples of substandard quality have been identified. We need accountability. Radiology must ensure timely reporting of any changes in interpretation so that we can rectify the misdiagnoses as quickly as possible. Resist the urge to tell the radiologist to contact the patients themselves and fix the problems they create. The last thing you want is the radiologist, with little vested interest, handling your risk management. Trust me. This is more your risk than theirs.