“Scrubs” and “ER”: Where’s the radiologist?

This issue of Applied Radiology focuses on Emergency—Trauma Radiology. In part, this is due to my personal interest in the topic, but more importantly, the choice reflects the growing importance of the emergency patient in our field. The doors of the Emergency Department (ED) compete with the hospital’s main entrance as a source of patient admissions, and a large portion of hospital revenues may be derived from the ED. The ED and trauma center can be exciting places to work, although perhaps not quite up to the comedic or dramatic level of television’s “Scrubs” or “ER.” Note that there is almost never a reference to a radiologist in these television emergency rooms. Is this the way it is in real EDs, or is it becoming so?

How should Radiology accommodate this growing emphasis on emergency care? The American Society of Emergency Radiology (ASER) boasts approximately 500 members with far-spread international involvement. A study by Hunter et al¹ surveyed academic radiology departments and found that more than half of the 278 responding institutions had an emergency radiology section for “wet-read” or immediate interpretation during the day and most provided night and weekend coverage, usually by residents. Sixty percent of the departments used teleradiology for emergency coverage.

The American College of Radiology (ACR) states that interpretation of imaging studies performed in the ED should be obtained in a timely fashion appropriate to the clinical circumstances and available local resources.² There is little discussion in the literature of how this coverage is provided and the clinical impact of various coverage levels. A few articles have suggested that the presence of attending-level faculty during “off-hours” generally improves quality, appropriateness, and timeliness of patient care; decreases institutional costs; and benefits patient management.^3-5 A few studies have compared radiology resident interpretation with attending coverage and found a relatively low rate (approximately 2%) of clinically significant discrepant interpretations that appear to be experience-related.^6,7

The matter of emergency radiology coverage is less clear for nonacademic sites and small radiology departments. Many groups have adopted teleradiology, which appears to be effective.^8,9 Smaller groups have often opted to allow these after-hours studies to be interpreted by nongroup radiologists, either locally or distantly (nighthawks), on a fee-per-study basis.

While the interest in and need for some form of rapid expert interpretation for many ED studies has become clear to the radiologic community, many questions remain unanswered. Among these are: 1) Assuming adequate image quality, is face-to-face interpretation significantly better than teleradiology for accuracy of image interpretation or enhanced patient-care decisions?¹⁰ 2) If in-house faculty are present, are covering residents in academic centers learning the interpretation skills and self-confidence needed for emergency studies and future practice? 3) Given the variety of modalities and diversity of body systems in emergency imaging, what previous training is adequate for radiologists who interpret emergency studies? 4) If teleradiology is used to provide emergent interpretation, should there be a set of guidelines for determining the type and number of images transmitted, for establishing adequate response time, and for accurately documenting medical indications and image interpretation results? Some, but not all, of these items are discussed in the ACR Standard for Teleradiology.¹¹ 5) Should all after-hours emergency imaging studies of any type be presented for interpretation, or only selected studies such as CT or MRI? 6) How can quality assurance and improvement using teleradiology interpretation be best achieved? Undoubtedly, there are many other questions related to this issue.

Answering these difficult questions requires carefully planned research and analysis. Cooperation among radiology residents, clinical services, and organized radiology will be needed. I hope the writers of the television emergency room series can eventually figure out that we exist and that we make a major contribution.