First-year residents not ready for call, simulation finds

A Harvard study appears to validate a decision by the Accreditation Council for Graduate Medical Education requiring at least one year of radiological training before residents are considered qualified to take call. A computerized simulation test used in the study showed that first-year residents may lack necessary imaging interpretation skills for the assignment.

Increasing workloads seen by radiology departments across the U.S. are putting an extra strain on residents, who are supposed to take overnight call and emergency duties as part of their training. As the need for sophisticated imaging exams mounts, intolerance for medical error and concern for patient safety remain high. Within this context, the ACGME changed the training requirement for radiology residents from six to 12 months before they take unsupervised call.

The move sparked controversy. Critics say the decision is arbitrary, deprives first-year residents of valuable learning experience, and promotes unfair comparisons between them and senior students. Opponents also argue that, beyond increasing minimum training requirements, the measure does not establish standardized guidelines on how to prepare residents or a method to evaluate their performance.

A computer-based simulation and testing program could, however, provide an objective assessment tool as well as a reliable before-call teaching tool, according to principal investigator Dr. Suvranu Ganguli, a radiologist at Beth Israel Deaconess Medical Center.

Ganguli and colleagues analyzed results of a DICOM-based simulation module used to test residents after a month-long emergency radiology lecture series ran from 2004 through 2008. The computer-based testing module included actual emergency room cases and helped investigators compare first-year and upper-level resident performance and call preparedness.

Researchers found, not surprisingly, that students improved their scoring as they progressed toward the last year of residency. They also found that first-year radiology residents scored significantly lower than did their upper-level colleagues despite the relatively low number of residents in each group.

Study results suggest the core curriculum training module alone did not prepare first-year residents to the level of call preparedness reached by their upper-level colleagues, according to the investigators. They published findings in the February issue of the American Journal of Roentgenology (2009;192:539-544).

Ganguli and colleagues wrote that findings also appear to support the ideas set forth by the Diagnostic Radiology Residency Review Committee of the ACGME. The committee decided that higher-level residents will perform more effectively in an independent call situation and therefore recommended a minimum of 12 months of training in diagnostic radiology before independent on-call responsibilities.

The study had several limitations, including case selection bias and the lack of a method to evaluate residents' ability to detect and manage incidental findings. Also, the testing computerized module was performed in a protected setting, which is unrealistic when compared with true overnight call situations. Further studies are needed to validate the ACGME recommendations for minimum competence among radiology residents before taking call, according to investigators.

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