ORIGINAL RESEARCH • SPECIAL REPORT

Overnight Resident versus 24-hour Attending

Radiologist Coverage in Academic Medical
Centers
Michael A. Bruno, MD, MS  •  James R. Duncan, MD, PhD  •  Andrew J. Bierhals, MD  •  Rafel Tappouni, MD
From the Department of Radiology, Penn State Milton S. Hershey Medical Center and Penn State College of Medicine, 500 University Dr, H-066, Hershey, PA 17033
(M.A.B.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (J.R.D., A.J.B.); and Department of Radiology, Wake Forest
University Baptist Medical Center, Winston-Salem, NC (R.T.). From the 2017 RSNA Annual Meeting. Received March 27, 2018; revision requested April 13; revision
received July 26; accepted July 30. Address correspondence to M.A.B. (e-mail: mbruno@pennstatehealth.psu.edu).

Conflicts of interest are listed at the end of this article.

See also the editorial by Meltzer in this issue.

Radiology 2018; 289:809–813 • https://doi.org/10.1148/radiol.2018180690 • Content code:

Academic medical centers have long relied on radiology residents to provide after-hours coverage, which means that they essentially
function with autonomy. In this approach, attending radiologist review of resident interpretations occurs the following morning,
often by subspecialist faculty. In recent years, however, this traditional coverage model in academic radiology departments has been
challenged by an alternative model, the 24-hour attending radiologist coverage. Proponents of this new model seek to improve
patient care after hours by increasing report accuracy and the speed with which the report is finalized. In this article, we review
the traditional and the 24-hour attending radiologist coverage models. We summarize previous studies that indicate that resident
overnight error rates are sufficiently low so that changing to an overnight attending model may not necessarily provide a meaningful
increase in report accuracy. Whereas some centers completely replaced overnight residents, we note that most centers use a hybrid
model, and overnight residents work alongside supervising attending radiologists, much as they do during the day. Even in this hy-
brid model, universal double reading and subspecialist final review, typical features of the traditional autonomous resident coverage
model, are generally sacrificed. Because of this, changing from resident coverage to coverage by an attending radiologist that is 24
hours/day, 7 days/week may actually have detrimental effects to patient safety and quality of care provided. Changing to an over-
night attending radiologist model may also have negative effects on the quality of radiology resident training, and it significantly
increases cost.
© RSNA, 2018

After-hours Coverage at Academic the following morning by an attending radiologist, 7 days

Medical Centers
Idirect patient care is provided by the so-called house staff:
n the traditional academic medical center training model,
interns, residents, and fellows acting with varying degrees
of autonomy with attending physician supervision. This
trainee-centered care model for the academic medical cen-
ter was created by Sir William Osler in the 19th century. In
this model, trainee autonomy progressively increases with
experience and seniority, with cascading supervision of the
house officers, whereby more senior residents and fellows
supervise those who are more junior, and all are supervised
by an academic faculty physician who meets with them at a
minimum on a daily basis. The attending physician reviews
the residents’ work and assumes responsibility for the care
provided by the house staff under their supervision.
In radiology training programs working under the tra-
ditional academic house staff model, imaging examina-
tions are initially interpreted by radiology residents, who
dictate preliminary reports that are finalized after review by
a supervising attending radiologist. After hours, radiology
residents function autonomously, with emergency depart-
ment and other clinicians basing their care decisions on
the radiology residents’ preliminary readings. This autono-
mous resident night coverage duty is limited to residents in
year 2–4 of residency. Resident overnight preliminary in-
terpretations are typically reviewed and finalized promptly
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a week. This so-called trainee-centered approach to patient
care has been a part of the educational process since the
first formal radiology residencies were established in the
late 1930s and 1940s. Radiology residents are required to
make independent decisions that have immediate effects
on patient care, but have a safety net of a delayed second
review and teaching input from the attending faculty in
each subspecialty. In this model, the residents’ reports are
not final because they are occasionally edited or even super-
seded by the subspecialist radiologist attending. The system
of double reading with feedback is expected to lead to
prompt detection of errors before they cause patient harm.
The training process also leads to progressive reductions in
both resident error frequency and severity over time.
Challenges to the Resident Coverage
Model
The traditional resident-based care model has been ques-
tioned in recent years throughout academic medicine
because of concerns for increasing the speed of care and
patient safety, with greater expectations for direct patient
care that is performed by the attending physician. As a
result, there has been a reduction in resident autonomy
across many medical and surgical specialties. The potential
for negative effects on the radiology training program has
been described (1).
Overnight Resident versus 24-hour Attending Radiologist Coverage
Summary
Available data indicate that overnight coverage by radiology residents
with delayed over-reading by subspecialist faculty has a low error rate
comparable to that of attending radiologists in the emergency setting.
Previous studies suggest that overnight radiology resident coverage
in teaching hospitals may improve final report accuracy primarily
because of the benefit of routine double reading.
Implications for Patient Care
nn Overnight residents functioning autonomously after hours provide
a high standard of care. Error rates appear to be low and compa-
rable to those of attending radiologists. Inherent double reading
facilitates rapid detection of errors.
nn Twenty-four hour attending coverage may reduce report turn-
around times and reduce the burden for emergency department
callbacks. Twenty-four hour attending coverage does not appear to
reduce patient length of stay in the emergency department, rates
of hospital admissions, or specialist consultations.
nn Twenty-four hour attending coverage reduces resident autonomy,
with negative implications for resident training and preparedness
for independent practice.
In radiology, the primary area where residents still function
with some degree of autonomy is when they provide after-hours
coverage. In recent years, a growing number of academic radi-
ology departments have considered or implemented after-hours
attending coverage (ie, an attending radiologist onsite 24 hours
a day, 7 days a week [hereafter referred to as a 24/7 attending]),
with varying degrees of resident involvement. The goal of after-
hours attending coverage is to improve report accuracy, expedite
finalization of reports, and improve patient care in the emer-
gency department setting (2). Potential benefits would include
increased throughput of patients in the emergency department
with less need to recall patients for discrepant readings. Radi-
ology attending coverage would also match attending coverage
of emergency physicians and trauma surgeons in institutions
where those individuals are also in house. The principal rationale
for implementing 24-hour attending coverage is three-fold: an
after-hours attending radiologist provides a higher level of care
than the traditional resident model, it allows a more rapid report
turnaround time for the emergency department, and presence
of an overnight attending radiologist enhances the status of ra-
diologists in the eyes of the emergency physicians and hospital
administrators.
There are two lines of evidence that raise uncertainties regard-
ing the preceding rationale: (a) substantial benefits of double
reading for error prevention in all aspects of radiology have been
clearly demonstrated (3), and double reading, although inherent
to the resident coverage model, is either diminished or lost in the
24-hour attending model; and (b) dedicated attending coverage
is typically associated with diminution or loss of subspecialist
radiologist final review.
Unless great care is taken to construct the 24-hour attending
coverage model, there is the potential for a two-tiered standard
of care in the academic medical center: full subspecialist-level
care offered for patients during the day and lower level of special-
ization for patients who are in the emergency department over-
night. For example, subspecialty-trained radiologists with neuro-
radiology or musculoskeletal radiology fellowships would act as
810 radiology.rsna.org  n  Radiology: Volume 289: Number 3—December 2018
generalists in other areas, such as chest or abdominal radiology,
when working overnight. A solution might be for these night
positions to be filled exclusively by emergency radiology sub-
specialists (ie, persons who have completed a year of emergency
radiology fellowship training), however, these subspecialists are
relatively rare because of the limited number of those training
positions and potentially lower interest by trainees (4).
Evidence regarding Accuracy of Resident
versus Attending Radiologist
In 1949 Leo Henry Garland, MD, (5) showed and subsequently
other researchers have shown that experienced, expert attending
radiologists are not perfectly accurate, but instead have a fairly
predictable error rate. The error rate of attending radiologists for
all types of radiologic studies, generally measured as the rate of
discrepant readings compared with their peers, has essentially
not been credibly measured below 3%–4% (6–8).
In multiple studies, radiology residents’ discrepancy rates for
significant missed overnight findings that were detected later by
attending subspecialized radiologists is similar to this and some-
times lower, often reported below 2% (Table 1). For this com-
parison, discrepancy rates between the preliminary resident and
final faculty interpretations are used as a proxy for rates of over-
night resident interpretive error. For example, a study by Cooper
et al (9) of a series of 141 381 examinations found that residents
had significant discrepancies with the final attending radiolo-
gist’s interpretation in only 1% of the cases, with slightly better
performance observed with greater resident experience. In 2016,
in a prospective study of resident on-call accuracy, Mellnick et al
(10) reported an average resident error rate of 1.4% on the basis
of a review of 153 420 examinations. In the same study, the rate
of critical discrepancy (ie, findings that are potentially life threat-
ening and that might require immediate or near-immediate
clinical management) was only 0.007%. Similar findings of a
low rate of resident-attending discrepancies leading to patient
management changes were published by McWilliams et al earlier
this year (16). However, increased error rates have been reported
in preliminary reports issued by residents (17) and faculty (18)
who work more than 10 consecutive hours overnight, and these
error rates have been attributed to fatigue and circadian effects.
Quality and Patient Safety Concerns
The principal quality and patient safety concern in switching
to a 24/7 attending for after-hours coverage is the compromise
of error detection from loss of double reading in the subset
of cases for which there is no resident involvement. Because
interpretive errors inevitably occur, a premium must be placed
on error detection for the prevention of patient harm. It is gen-
erally accepted that perceptual errors, in which abnormal find-
ings are simply not perceived despite being deemed obvious in
retrospect, are the primary type of error that radiologists are
prone to making (5–7,19). These errors appear to be random
in occurrence, and since Garland’s time, the only remediation
that has been shown to be effective for these types of errors is
double reading, as Garland recommended (5), and which has
been recently discussed in these pages (3,20). This benefit is at

Table 1: Accuracy Rates in the Literature of Resident Overnight Interpretations
Author Year Published No. of Examinations Discrepancy Rate (%)
Cooper et al (9) 2008 141 381
Mellnick et al (10) 2016 153 420
  Emergency department
 Inpatient
Weinberg et al (11) 2015 416 413
Kung et al (12) 2013 2219
Tomich et al (13) 2013 193 722
Branstetter et al (14) 2007 65 780
Carney et al (15) 2003 929
Note.—Table summarizing evidence of residents’ high degree of interpretive accuracy as shown in seven
published studies over the past 15 years (9,10,14–18).
*Data are average; data in parentheses are range.
least partially lost with the move to an overnight attending ra-
diologist, whose interpretations are both immediate and final,
and will generally not be reinterpreted by a subspecialist the
following day.
The double-reading model recognizes that a resident’s skill in
interpreting a particular image almost certainly falls below that
of the specialist who later reinterprets the image. It is understood
that residents’ overnight interpretations will contain errors but
that most are discovered and corrected the following morning.
Error detection and correction not only allows for improvements
in the trainee’s mental model but also enhances overall quality of
care and patient safety. Double reading, along with a typically
higher degree of subspecialization in the final review, are key ele-
ments of the high standard of care inherent to the traditional
resident coverage model.
The power of double reading in the trainee-and–attending
radiologist dyad model was highlighted in a recent study by
Balthazar et al (21), which showed that radiology reports gen-
erated without trainee involvement were up to 12 times more
likely to include a later addendum than were reports with trainee
involvement. The need for an addendum is generally indicative
of the presence of one or more errors in the radiology report that
were discovered only after the report was finalized by an attend-
ing radiologist. Arguably, the main benefit of trainee involve-
ment in this study was from double reading. The results provide
an estimate of the value of double reading toward improving
report accuracy: double reading may have provided as much as
a 12-fold benefit.
Together, these data on the low rate of resident interpretive
discrepancies and the power of double reading for error detection
support the conclusion that an overnight attending radiologist
will not reliably provide a higher level of interpretive accuracy
than the traditional resident-and–attending radiologist dyad.
Training Mission
There is evidence to suggest that the loss of resident autonomy
after hours is harmful to the educational mission in radiol-
ogy, and this has been noted in other specialties (22). Collins
et al (1) published the results of a survey of six academic medi-
cal centers showing that the majority of faculty and residents
Radiology: Volume 289: Number 3—December 2018  n  radiology.rsna.org 811
Bruno et al
surveyed felt that the loss
of resident autonomy had
negative effects on resident
1.0 training and their subsequent
confidence regarding en-
1.35 tering the field as indepen-
1.8 dent practitioners. In this
1.7 survey, residents in pro-
1.8 grams with 24/7 attending
0.33 (0.23–0.42)* coverage reported to have
1.9 initially interpreted only
1.0 46% of examinations, and
the balance was only inter-
preted by a faculty mem-
ber, compared with 81%
of examinations initially
interpreted by a resident in
programs with traditional resident-centered after-hours cover-
age. In another survey published in 2016 (23), 38% of radiol-
ogy residents reported that a 24/7 attending coverage model
had a negative effect on their ability to independently interpret
studies. Most concerning was that more than 50% of 4th-year
residents cited this negative effect, whereas 43% of all respon-
dents were neutral regarding this question. Other negative ef-
fects to resident education from the switch to 24/7 attending
coverage have also been cited in the literature (24). However,
one single-institution, survey-based study (25) reported that
residents felt positively about the addition of an overnight at-
tending, with less anxiety, apprehension, and stress related to
their after-hours work and with no significant decrement in
their interpretive confidence after their department instituted
an overnight attending physician.
Despite the subjective worsening of the stresses related to
after-hours call, in our collective experience we noted that inde-
pendent night call for residents has recently become an attractor
for candidates who choose a radiology residency.
Cost and Cost-effectiveness
Published data regarding the cost effectiveness of an overnight
attending radiologist are limited. In their article, Coleman
et al (26) discussed whether their in-house 24/7 attending
coverage was cost effective. They noted that their report turn-
around time for cases in the emergency department was sub-
stantially improved, however, this benefit did not translate
into any measurable decrease in patient length of stay in the
emergency department, which was their target metric. These
authors concluded that the cost-related results of the change
were disappointing.
The costs of providing a workable overnight service are
high—typically several qualified individuals must be re-
cruited, all of whom must be comfortable interpreting
the full range of radiologic studies in the necessary rapid
timeframe, and all of whom are willing to work entirely (or
primarily) at night. A recent radiologist manpower survey
(27) by the American College of Radiology suggested that
the demand for after-hours radiologists exceeds the available
Overnight Resident versus 24-hour Attending Radiologist Coverage
Table 2: Comparison of Traditional Resident versus 24-hour Attending Coverage Models
Resident Coverage with
Subspecialist Over-reading
Effect (ie, Traditional Model)
Quality and safety Strongly positive  Moderately positive
Final report turnaround time for Weakly negative
  emergency department
Resident education and preparedness Moderately positive
Cost Low
manpower supply. Whereas nighthawk services abound in
the private sector, the nighttime work schedule may be
viewed as undesirable in the academic setting (perhaps seen
as potentially interfering with academic career advance-
ment), therefore making recruitment and retention of night
radiologists an even greater challenge for an academic radi-
ology department. Coleman et al (26) reported that at their
institution the radiology faculty who work at night in the
emergency department received an 18% salary premium.
Most academic departments also provide extra paid vaca-
tion time to overnight radiologists, often in the form of a
work schedule that consists of 1 week working and 2 weeks
not working. Despite the higher salary, generous time off
and other benefits, concerns for high stress levels and an in-
creased risk of burnout among night radiologists along with
relatively high job turnover have been reported (28,29) with
associated recruitment-related and other costs.
Summary
Although the overnight attending radiologist model is in-
creasing in popularity and accounts for up to 50% of ac-
ademic centers by some estimates (2), there is reason to
question whether this model provides measurable benefit
for patients, such as reducing length of stay in the emer-
gency department, reducing the rate of hospital admissions,
or clearly improving diagnostic accuracy. The overnight at-
tending radiologist model also eliminates an effective means
for error detection and harm prevention, namely routine
double reading of all overnight images, and in some sce-
narios this model may also create a lower standard of care
(ie, less subspecialized) for after-hours services. This model
also appears to have detrimental effects on residency train-
ing, which could compromise the future viability of the sub-
specialty of diagnostic radiology. If we sacrifice the training
of future radiologists for expediency, this is akin to eating
the seed corn; there may be short-term gains in customer
satisfaction, but we will ultimately produce a long-term
decrement in patient care (Table 2). However, radiology
departments that use residents for overnight coverage must
commit to continuously monitoring rates of interpretive
discrepancy, and must be prepared to take swift remedial
action if needed.
It is worth noting that in the future, improvements in
computer-aided detection made possible by advances in
machine learning and artificial intelligence applications in
812 radiology.rsna.org  n  Radiology: Volume 289: Number 3—December 2018
24-h Attending Coverage 24-h Attending Coverage
with Initial Resident with Limited or No Resident
Interpretation on All Studies Involvement
Weakly negative
Weakly positive Moderately positive
Weakly negative Strongly negative
High High
radiology may provide a feasible alternative to radiologist
double reading; such systems would provide equal benefits
in error reduction to both resident and attending radiolo-
gists, and thus are not likely to affect the decision regarding
whether an academic department should switch from the tra-
ditional resident-coverage model to the overnight attending
model.
Despite our concerns and the evidence that supports them,
we acknowledge that the observed trend away from the tradi-
tional resident coverage to an overnight 24/7 attending model
will likely continue. The transition to overnight attending radi-
ologist coverage is also likely to be an irreversible one for most
academic departments because the perception that it represents
a higher standard of care will impede returning to the tradi-
tional model.
The trend toward switching to overnight attending radiologist
coverage in academic radiology presents our specialty with numer-
ous complex challenges and unintended consequences. It is our
hope that academic radiology departments will consider these
ramifications carefully in weighing their options and future direc-
tions, particularly regarding potential negative effects on quality
and patient safety, and the effect that the presence of an overnight
attending radiologist has on resident training, autonomy, and
preparedness.
Acknowledgment: The authors acknowledge with gratitude the editorial as-
sistance of Jason Itri, MD, in the revision of our manuscript.
Author contributions: Guarantors of integrity of entire study, M.A.B., A.J.B.;
study concepts/study design or data acquisition or data analysis/interpretation, all
authors; manuscript drafting or manuscript revision for important intellectual con-
tent, all authors; approval of final version of submitted manuscript, all authors;
agrees to ensure any questions related to the work are appropriately resolved, all
authors; literature research, all authors; and manuscript editing, all authors
Disclosures of Conflicts of Interest: M.A.B. disclosed no relevant relation-
ships. J.R.D. Activities related to the present article: disclosed no relevant relation-
ships. Activities not related to the present article: disclosed money paid to author for
consultancy from U.S. Department of Justice; disclosed expert testimony for cases
involving interventional radiology; disclosed grants or grants pending for National
Institutes of Health; disclosed payment to author for lectures from Bayer Healthcare
and Washington State Hospital Association; disclosed stock/stock options in Pro-
tean. Other relationships: disclosed no relevant relationships. A.J.B. disclosed no
relevant relationships. R.T. disclosed no relevant relationships.
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