Radiology night shifts are a frenzy. Maddenly, absurdly difficult. An older internal medicine doctor once asked me “oh, do you get to sleep during your call shifts?” and I scoffed. Sleep?! We hardly have time to go to the bathroom!
Labeling radiology nights as “call” is misleading, suggesting that we only spring into action when some rare clinical circumstance occurs (like checking if a baby’s bowel is twisting itself off). “Night float” gets closer, implying a skeleton night crew takes over to cover overnight emergency issues (like if a patient in the scanner requires special attention). I mean, we do those things too, but the commodity of modern radiology is incorporated real-time into many diagnostic workups, so we’re basically ALWAYS needed.
Practical
Nights are 8 pm to 7:30 am, six shifts in a row. After two late-shift co-residents leave at 1 am, I’m left alone to run the department alongside a remote radiology night attending. I’m expected to read on average about 45 CTs, 15 ultrasounds, and 45 ER x-rays churned out across two hospitals and emergency rooms. That is A LOT. Maybe it’s manageable for a seasoned attending radiologist (who signs off on 160 studies a night), but for us trainees with as little as 1.3 years of training, it’s a formidable workload.
Plenty goes into the act of radiology reading. Primarily, there’s the raw visual inspection of the images: scrolling through digital images, correlating with our understanding of anatomy pathology, and divining findings and diagnoses. Secondarily, there is generating the text for radiological reports, using a combination of pre-populating templates (which I designed beforehand), rapid dictation, and quick proofreading in a word processor (as opposed to signing off on third party transcriptions).
The patient’s entire radiological history is available for perusal, and we are obligated to compare when necessary. To supplement that, often we need to open the patient’s chart for a glimpse into the clinical context. We’re also responsible for “protocoling” studies before they’re performed: reviewing a study requisition and deciding upon specific timings, anatomic delimitations, and other technological specifications. Sometimes, we have to call ordering providers for clarification. Sometimes, we perform a courtesy call to communicate important findings in a timely fashion.
Notably, we answer any radiology-related questions anyone calls with overnight, up to and including “wet reads,” which amounts to reading a study, live, over the phone, upon command. This typically necessitates dropping our train of thought on whatever dictation we were working on. That amounts to being interrupted by 79 phone calls each night on average (I counted for four nights), with calls heavily concentrated early on (up to 21 in one hour).
Mental
Frame it as such: in an average shift, we’re mini-consulted 79 times while we’re trying to treat 105 patients. It’s discombobulating. The mental burden incurred by the task-switching for phone calls is immense. An analogy: it’s neither polite nor safe to force a surgeon to scrub out whenever someone calls the OR to perform an unbilled procedure without full clinical context, but that’s kind of what aborting a read to perform a wet read feels like.
True, radiology isn’t as in-depth as primary clinical medicine (which I’ve done too). However I actually found that the thoroughness of primary medicine incorporates some fluffy, less intense work into a call shift, tasks like walking around, charting, and talking to patients (lol). Essential work, for sure, but dilutional. In contrast, the density of medical decision-making in radiology nights is crushing. Our technologists acquire images faster than we work, performing the patient positioning, parameter tuning, and ultrasound probe manipulation on our behalf. We don’t need to wait for transport, hemostasis, or patient cooperation… We just perform the crux of the job constantly: read, read, and read some more.
The rapidity of the scanning means we have to rely on our instincts. We need to believe in our preparation, our eyes, and our medical understanding so we can reflexively generate meaningful dictations. There’s not much of a break for documentation either. We learn to think aloud and dictate quickly, perhaps 150-200 wpm, a skill in itself. I should probably proofread more instead of letting through embarrassing and occasionally consequential typos, but alas, I’m always in a rush to get back to the list.
Emotional
Oh, the list. ALL OVERNIGHT A AND V. It’s our eternal struggle to clear the list. My anxiety spikes when I close a completed study and the list taunts me with how much it’s grown while I was reading. My heart sinks when I see my spot on the list sink lower and lower, pushed downwards by neverending fresh studies. If I ever need to scroll down, I know I’m screwed.
There’s plenty of variability, where straightforward scans only need a few seconds but a trainwreck metastases-everywhere scan can necessitate 30-45 minutes. I dread those. Oh yeah, remember emergencies like the babies with twisting/dying bowel, or a patient coding in the scanner? A pediatric fluoroscopy study can set us back 90 minutes, and the deficit on the list becomes indomitable.
I’m motivated by my duty as a doctor: wanting the patients to do well, hoping referring doctors value my work, wishing to maintain good standing in the radiology department, and just trying to stay proud of my output. But when my adrenaline wanes and the responsibilities exceed the limits of my abilities, I wish there could be space and time for a breather. Maybe slack off for a scan or two.
But where is it safe to try cutting corners? These scans are real people, and radiology reports are permanent, legal documents. There’s no medical legal exemption that relieves my liability just because I was reading when busy overnight. There’s no moral leeway for letting a patient down because they were stricken on the wrong side of the clock.
I hate it when people are disrespectful over the phone. Hate, hate, hate. Calls like “we’ve been waiting for a read for over an hour and a half, so…” or “why is this still an issue? We’ve been calling since day shift.” Calls like that rattle me, knock me off my game. My speed falls and my critical miss rate rises if I’m emotionally askew, and that can fuel a dangerous cycle of self-doubt.
The day isn’t over when I deliriously bike home and collapse into bed. After I wake up, I login from home to follow up on addenda to my reports, trying to internalize teaching points. I go down my spreadsheet of patient charts to verify my radiologic diagnoses and log a fresh batch for future tracking.
Physical
There’s an enormous physical toll on the body. 12 hours on shift, plus 1-2 more hours review at home, six days straight, bookended by a usual diurnal schedule (I’m terrible at rapidly reversing my sleep schedule). Sustaining my energy through the morning is tough, exacerbated by the poor sleep I get with NYC blaring outside and with sunlight beating down.
Staring at high-resolution, high-luminosity radiology monitors is a strain on the eyes, especially at night, in a dark basement room. With speedy scrolling through CTs, there’s a lot of intent, unblinking gazing. Often, by the morning, my bleary eyes can barely maintain focus.
A standing desk helps, but nonetheless a full shift of sitting and scrolling is taxing. My right wrist, shoulder, and parts of my back are frequently sore from long-term high-precision mousing through image stacks and reports. Anyone who has binge-played FPS or RTS video games knows the strain I’m talking about.
There’s not much time to eat nor nutritious food to be eating. Aside from junk food at the workstation, I try to consume a microwaved meal around 4 am to supplement the meals I cram in at home.
It’s been more than two weeks since I got off nights; I wanted to write this during my actual week of nights, but I had no energy. I’ve finally made up for my sleep deficit, gained back the few pounds I lost, and healed the rare canker sores that erupted.
The Payoff
Each physician in every specialty has an analogous gauntlet, and most other specialties are more spectacular, more urgent, and more stereotypically doctorly. A grueling complex surgery. A difficult conversation with a dying patient’s family. An emergency code situation where life-and-death decisions are made in the matter of seconds.
Our “hard mode” is unflattering: hunkered in a four-monitor workstation, scrolling through a CT or three while troubleshooting a protocoling issue on the phone while another phone line rings while a surgery PA hovers behind waiting to ask a question. I know I’m lucky in radiology, with my 24/7 attending coverage, a generally pampering residency, and the privilege of punting many in-person emergencies to other services. While I may grumble about the predictable difficulty of nights, that predictability is the gift that enables me to prepare.
Believe me, in those weeks of radiology nights, we pay our dues. We test our efficiency, confidence, and resilience to the utmost degree. Respect the night radiology resident.