US radiologists, like most Americans, are not keen on working the overnight shift -- but that is where the work load is increasing, physicians and teleradiology companies told United Press International.

That development, combined with a shortage of radiologists that has appeared over the past seven years or so, means providing radiological services around the clock has become a serious problem. The issue is not outsourcing of radiologists -- it is any source of radiologists, experts said.

On-call radiologists, who once were contacted at home perhaps once a night to read an X-ray or MRI, now find themselves dealing with four or five calls and getting little or no sleep -- only to have to report to work in the morning. Aside from the risk of having a tired radiologist read a crucial scan, there is the toll such sleep deprivation takes on a doctor's health and family life.

Technology that once produced only fuzzy images now permits Internet transmission of crystal-clear radiological scans, so more and more hospitals and radiology practices are contracting with so-called nighthawks -- radiologists who do not mind covering night shifts in the United States because where they are -- across the globe in Israel, Australia or Switzerland -- it is daytime.

Dr. Paul Berger began this trend in 1994 by establishing NightHawk Radiology Services out of Coeur d'Alene, Idaho, his son Jon, a company vice president, told UPI. The company's operations manager, who had been a helicopter pilot in Vietnam, coined the term "Nighthawk" because that was the nickname for pilots who flew night missions.

Today, NightHawk Radiology provides overnight radiology services for hospitals and radiologist practices in 46 states. "Demand is very high and is growing," Jon Berger said. "From our perspective, I don't think we'll ever go back."

The success of this business venue is not without challenges, however. There are issues of credentialing, licensing, accuracy of the readings, liability and public perception -- based on recent reports linking nighthawk services with moving jobs out of the United States to foreign countries with cheaper labor and less-qualified staff.

Most of these concerns already have been answered by the nighthawk companies and radiologists themselves. They maintain strict requirements that all teleradiologists be U.S. trained, licensed and board certified.

The gold standard is a nighthawk radiologist will relocate his or her own job overseas -- but still must hold a license to practice medicine in each U.S. state where contract clients are located and also be individually credentialed by each hospital for which the work is done.

Along with those requirements, UPI was told, comes a paycheck equal to -- if not more than -- what an average radiologist would make stateside.

Susan Larm, of Worldwide Rad, a nighthawk radiology company in Cleveland, told UPI the technology has moved from more primitive e-mail delivery to having a private Web server to send scans to radiologists in Australia, Israel and Italy.

"They have the same system any other U.S. doctor would have," she told UPI. "The stations there are exactly the same as they would (be) in the United States."

There are a few teleradiology services overseas that use local staffing, but if they do not meet the credentialing and licensing standards they cannot perform even preliminary screenings for U.S. hospitals. At best they can provide sub-readings that would have to be verified in the United States anyway.

Nevertheless, reports of such businesses and the growing nighthawk trade have caught the attention of the American College of Radiology, which has set up a Task Force on International Teleradiology. Task force members have studied the issue and will present recommendations at the 81st Annual Meeting and Chapter Leadership Conference that begins Saturday in Washington.

The recommendations, posted on the ACR Web site, include requirements for state and local licensing, credentialing and appropriate medical liability coverage in each state. The task force also recommends state radiologists "be responsible for the quality of the images being interpreted."

Dr. A. Van Moore, task force chairman and a practicing radiologist at the Carolina Medical Center in Charlotte, N.C., told UPI his group looked at some of the problem issues that might develop and require concern.

"The medical legal issues ... are not clear," Moore said. "There still are a lot of questions that need to be answered there. There is no case law that gets down into this."

The United States has no jurisdiction outside its borders, so there are questions about what could happen if a teleradiologist in Australia, for example, were sued for malpractice. Moore said the hospital would be liable but the radiologist is under no obligation to come to the United States for trial.

While there does not appear to be an existing problem, Moore said concerns remain that companies might recruit people who are not U.S. trained and certified.

The task force, he added, generally found no problem with relocating a U.S. trained radiologist to another country, but "what we would say is that those radiologists should be subject to a quality assurance process that would be equal to or exceed that of the facility for which they are providing those services."

Dr. Leonard Berlin, chairman of Department of Radiology at Rush North Shore Medical Center in Skokie, Ill. -- a suburb of Chicago -- said accuracy of the readings has not been an issue with nighthawk radiologists that contract with the hospital.

Berlin, who also is a professor of radiology at Rush Medical College, said the nighthawks actually follow the same two-read process that would occur if the readings had been done by radiologists in the hospital.

A nighthawk does a preliminary reading of the X-ray or CT or MRI -- which can be used if immediate treatment is required -- but then in the morning another staff radiologist in the hospital follows up with a final read.

This provides backup and, in the case of teleradiology, cuts through the problem of Medicare not paying for radiology readings done outside of the United States.

Still, Berlin wonders if "this is going to come back to bite us," if hospitals administrators begin to see an economic advantage to using the nighthawk services during the daytime as well -- potentially putting some jobs at risk.

He worries, too, about the possibility a U.S. radiologist might subcontract a reading to a service in a foreign country that might not require the U.S. standards and simply put his or her name on it.

"That would be fraud," Berlin said, and added the ACR next week will consider a statement declaring any practice in which a radiologist puts signs a reading he or she has not personally interpreted to be unethical.

"It's a shame we even need the statement," he said. "I would hope it's very rare -- I haven't seen it personally."

As the profession sorts out teleradiology, there does not appear to be much hope on the near horizon for additional radiologists to enter the field. The number of residency slots at medical schools are set and subject to the whims of federal funding.

Despite a comfortable six-figure salary, the profession is hard-pressed to fill vacancies throughout U.S. facilities -- rural and urban alike -- and the whole issue of working overnights, as well as the increasing night-time work load coming out of hospital emergency departments, has created a perfect storm of sorts for nighthawks.

Such was the case at Rockingham Memorial Hospital in Harrisonville, Va., until Rockingham Radiologists Ltd. Contacted with NightHawk.

Dr. Andrew L. Wagner, a Rockingham partner, told UPI although there are U.S. based radiologists who contract with other hospitals, there was an issue of turf.

"We didn't want a group who already had their own hospital to take care of because we were worried about our studies not getting priority," he said.

Wagner has authored a study for the Journal of the American College of Radiology that assesses his group's experiences.

"The nighthawks give an initial report and it gets a second interpretation," he told UPI. "We tracked it and the error rate was no bigger than our internal error rate."

Wagner's report found a 3.5 percent growth in diagnostic radiology volume per year, with much of it coming in more time-consuming and technical imaging studies, such as MRIs. He said the staff was exhausted working half the night and then the next day. It is a problem because radiology requires more concentration than many other professions, Wagner noted.

"You are looking for very subtle things -- you can't have your mind wandering -- you risk missing things," he said.

Still, the hospital did not have the volume to require full-time, in-house staffing, so Wagner began figuring out costs for a teleradiology contract.

According to his study, it cost $7,000 per radiologist on staff, per year, to provide after-hours readings at home. The glitch was the nighthawk services used a variable pay schedule -- meaning if the monthly average number of studies was not realized, the contract still required full payment. If more cases than negotiated for were realized, however, the additional readings would be extra.

"This fee system markedly increased how much we would pay. In fact, as the number of studies overall has continued to increase, the actual cost has been about $14,000/radiologist/year," Wagner wrote.

"Given that each partner has taken approximately 40 nights of call each year, it means that we are paying $350 per night to not take call, a price that everyone in the group was willing to pay, and much less than it would cost to hire another radiologist to allow a nighttime shift."

Wagner said he was worried about the reaction in the hospital to teleradiology but only one physician complained and later had admitted "in all honesty, if he could have done the same thing with his night call, he would have."

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