'Nighthawk' radiologists read X-rays, MRIs from hundreds of miles away

A person suffering an apparent stroke is rushed to a hospital in Ventura County, Calif. sometime after 7 p.m. Almost instantly, e-mailed images of the patient's brain emerge on Dr. James Brull's computer in Hays, Kan.Brull is a nighthawk -- one of a growing group of specialists who read complicated X-rays, MRIs and CAT scans at night from hospitals that might be located nearby or hundreds of miles away. Brull, who has staff credentials at about 1,000 hospitals across the nation, studies the images on four computer monitors then dictates a preliminary diagnosis that is transmitted back to Ventura CountyAnd it all happens within an average of 20 minutes.As part of a reliance on distance medicine and technology spreading throughout the healthcare industry, radiology groups from at least six hospitals in Ventura County outsource their night coverage. When a patient shows up in the emergency room after-hours, his or her scans likely will be transmitted off-site -- as nearby as Alhambra in the San Gabriel Valley or, in Brull's case, to a remote Kansas town once roamed by Wild Bill Hickok and George Armstrong Custer."Literally, I can be almost anywhere and be working for NightHawk Services," Brull said in a phone interview from his car after a stint reading images from Milwaukee.Radiology groups for at least five hospitals in Ventura County use NightHawk, a company in Coeur d'Alene, Idaho, that serves about 1,500 hospitals nationwide. NightHawk sends images to 120 board-certified radiologists across the country as well as in Sydney, Australia, and Zurich, Switzerland.Although Brull occasionally works on images sent from Community Memorial Hospital in Ventura, radiologists from that hospital and several others in the county said the bulk of their night work is sent to nighthawks in Southern California, and all of it remains in the United States. They said the service means patients receive quicker treatment and have access to radiology specialists all hours of the night.Radiologists and hospital officials said the program relieves pressure on doctors who already work long hours."We wanted to keep our doctors rested and clear," said Dr. Stanley Frochtzwajg, chief medical officer at Community Memorial Hospital. "If they don't have to stay up all night, they'll perform much better."As technology has increased, so has the use of computerized scans that can detect spinal injuries, complicated fractures, head trauma, heart problems, blood clots and other abnormalities. Dr. Charles North, a senior radiologist based at Community Memorial, said an emergency room might see 10 to 20 radiology cases a night, and each can include hundreds of images.Hospitals and radiology groups either have to ask their staffs to work marathon hours, hire more hospital-based radiologists or find nighthawks."It's cheaper to contract it out," said Jim Lott of the Hospital Association of Southern California, and it helps patients.Medical experts say the lack of direct contact with a patient isn't important, because everything the radiologist needs for a preliminary diagnosis is contained in the computerized scan or X-ray. They note that even hospital-based radiologists don't typically interact with patients when reading their images.A task force at the American College of Radiology voiced concerns about the possibility of overseas doctors working as nighthawks without proper credentials. But hospitals require all off-site radiologists to have staff credentials and be certified by the American Board of Radiology.Even the doctors employed by NightHawk in Australia and Switzerland were trained in the United States and transported abroad.The task force also worried about "ghosting," in which a freelance radiologist signs off on work done by unqualified support staff.But companies like NightHawk prohibit ghosting. All of their diagnoses are considered preliminary and are reviewed the next day by hospital-based radiologists. In some critical situations where a final diagnosis is needed immediately, hospitals call in on-site radiologists.NightHawk, one of many companies that offer distance radiology, was started seven years ago by Dr. Paul Berger, a Long Beach radiologist. He was pushed by the realization that the need for 24-hour coverage was causing doctors to burn out or ask for more money.He opened a radiology-reading center in Sydney, because the time change meant doctors working in the day in Australia could offer night coverage for hospitals in America. Now, reading centers have been set up in Zurich and San Francisco.The vast majority of readings were once sent abroad, but now about 80 percent of the work happens in the United States, much of it conducted from doctors' home offices, said Scott Giordanella, NightHawk's marketing director. Some hospitals request their images not be sent abroad.Images are compressed, so hundreds can be sent in an e-mail over a secure network. If questions arise, the emergency room doctor can call the radiologist.Private hospitals don't hire their own radiologists, instead contracting with groups that provide hospital-based doctors. Some of the larger groups offer 24-hour coverage, but many others contract with groups like NightHawk.They say there's just too much night work."It's unrealistic for us to provide this service and to be able to function the next morning as a radiologist. It's become pretty much the standard of care," said Dr. Ivan Hayward of Pueblo Radiology Medical Group, which uses NightHawk to provide coverage at hospitals in Oxnard, Camarillo and Ojai.(Tom Kisken is a reporter for the Ventura County Star in California.)