Sunday, June 19, 2005

Night Call

PACS: n. (acronym)
Picture Archiving and Communications System. A device or group of devices and associated network components designed to store and retrieve medical images.

This four-letter acronym has totally changed how we radiologists practice our trade. Gone are the days of huge sheets of film, developing trays and machines, and even file rooms. We are freed to work with the actual information of the radiograph or scan; no longer is this data irreversibly coupled to a sheet of plastic. I can view the image from my office 50 feet away from the scanner, from my home 5 miles away, or from literally anywhere in the world where internet access is available. Simply put, I can sit here and read from there, wherever here and there might be.

There are more consequences to this portability than the inventors of PACS might have envisioned. Early on, we heard a lot about "Swoop and Snatch" operations, wherein big, national operations might convince a hospital to turn over all imaging to their central office, shunning the local rads. We hear about this periodically today, but unlike the banking industry, Radiology has not yet consolidated into a few big national operations ala Wachovia and BankAmerica. There is at least one curious attempt at a franchise in PACS, Professional Radiology Solutions, having the underlying implication that the state-by-state owners are to scour their region for business. They require in their contract that a radiologist devote 10 hours per week in marketing, on top of a pretty hefty initial fee (hundreds of thousands of dollars). So far, we have received "courtesy" calls from the local state franchise rep informing us that they have contacted sites we cover, but of course they wouldn't think of trying to grab our business, they just want to provide PACS services. Uh huh.

PACS also changes the face of night work, more for better than for worse. Night call has become somewhat of a nightmare for most of us. A "good" night involves taking only 4 or 5 studies after midnight, but on an average night, we get at least 10-15 exams. One solution for this PM overload is to hire an in-house nighthawk; great if you can get one. Here in our "average city in the South" with nothing much interesting to do, we aren't going to find someone willing to do nothing but night-work. Just won't happen. Most groups now use some form of teleradiology, now incorporated into PACS, to allow the rad on call to read from home, certainly better than being stuck in the hospital, right?

If you can send the images to the guy (or gal) on call at home, you can send them anywhere the rad might happen to be, and of course, you can send to anyone else who has the proper equipment and authorization to receive them. So, it made sense to form companies that do nothing but take night call, affectionately called "nighthawks", a generic term which includes the largest such operation, Nighthawk Radiology Services. You pay them per night or per study, and they give preliminary reports (unless you make arrangements for them to do final interpretations.) These services usually place their rads on the West Coast, or in Hawaii, or in Australia, or in Europe or Israel; when it's night here, it's daytime there, and wouldn't you rather have your head CT read by someone who is fully awake at the time? I would. As an aside, some groups are establishing outposts in other time zones and hiring someone there or sending someone weekly to staff them. My group toyed with this idea but ultimately figured that by the third or fourth required rotation, most of my partners would balk at making the trip. Nothing like a 9-hour flight to dampen your enthusiasm about a trip to Hawaii.

Hiring a nighthawk service cannot be taken lightly. Their rads will be the face your group presents to your referrers at night. To me, it is very much like hiring a partner. You have to get someone with the right abilities and such; you don't just hire the first one that applies. There is a lot being said online about foreign nighthawk companies using untrained physicians (or nonphysicians, for that matter..cough cough Wipro cough cough) reading under sweatshop conditions. Obviously, your night-readers should have the same qualifications as your day-readers, i.e., US training, and certification, and medical licensure in your state. One could argue that some of these 'hawks become better at the usual ER studies, e.g., trauma radiology, having tremendous experience over time.

The decision to use or not to use a call-service becomes purely political, once you ensure the quality of the readers. We are about to take on a new site that has a nighthawk service in place. (The new place is an academic/county hospital, by the way.) Our plan is to phase out the call-service, and eventually have a rad in-house all night long, reading from the new place as well as all other sites in our own little "war-room". Why revert back to in-house call? It is a problem of perception. Some of my partners perceive that the surgeons and other "real doctors" will see us as "weenies" or "lazy" if we stick with the call-service. There has been some negative talk about the service, though it seems mainly to involve comments about radiologists who would "shirk their responsibilities" rather than the quality of the nighthawk service's reads. But I have a question: Why would it be OK to hire someone to do nothing but night call, but we are "weenies" if we hire a service, staffed by equally (or more) competant radiologists to do the same thing?

So far, we have had luck recruiting new members, but some recent threads on lead me to think that the new crop of radiologists coming out of residency won't even look at a job that doesn't use nighthawks. I guess we'll find out....

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