ISSN:(O) 2320-5407, ISSN(P) 3107-4928 Int. J. Adv. Res.

13(11), November-2025, 292-303

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/22114

DOI URL: http://dx.doi.org/10.21474/IJAR01/22114

RESEARCH ARTICLE

NIGHT SHIFT DIAGNOSTIC PERFORMANCE AMONG SENIOR RADIOLOGISTS: A

SYSTEMATIC REVIEW AND META-ANALYSIS OF FACTORS AFFECTING
EXPERIENCED PRACTITIONERS
Sisaid.Meliani, K.Meliani, M.Kouadri, O.Ayouche, N. Bouknani , S.Berrada and A.Rami

1. Radiology Department ,-Cheikh Khalifa International University Hospital, Casablanca, Morocco Medicine
Faculty, Mohammed VI University of Sciences and Health – UM6SS,Casablanca, Morocco.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Although night-shift performance is well studied among
Received: 06 September 2025 residents, the diagnostic accuracy of board-certified senior radiologists
Final Accepted: 08 October 2025 remains insufficiently characterized. Senior radiologists (≥5 years post-
Published: November 2025 training) often deliver final interpretations without secondary review,
yet their vulnerability to fatigue and circadian disruption is not well
Key words:-
Senior radiologists; Night shift; quantified.
Diagnostic accuracy; Attending Objectives: To systematically assess diagnostic accuracy during night
physicians; Circadian rhythm; shifts among experienced radiologists and evaluate factors influencing
Teleradiology; Healthcare
performance, including age, practice setting, and temporal patterns
workforce,Error rates; Fatigue; Meta-
analysis across the night.
Methods: A comprehensive search of PubMed, EMBASE, and Web of
Science (January 2000–December 2024) identified studies reporting
quantitative error rates or direct night-day comparisons for senior
radiologists. Data synthesis followed PRISMA 2020 guidelines.
Random-effects models were applied; heterogeneity was assessed using
the I² statistic, and publication bias via funnel plots and Egger’s
regression.
Results: Eighteen studies encompassing 203,097 interpretations met
inclusion criteria. The pooled major discrepancy rate was 2.03% (95%
CI, 1.71–2.35%) during night shifts versus 1.32% (95% CI, 1.09–
1.55%) during daytime, corresponding to an OR of 1.56 (95% CI,
1.49–1.62; p<0.001). Performance remained stable before 2 AM but
deteriorated significantly afterward, with peak errors between 4–6 AM.
Radiologists over 52 years showed a 78% greater susceptibility to
circadian effects compared with those under 48 years. Teleradiology
settings had higher error rates than on-site coverage (2.31% vs 1.68%;
p<0.01). Extended sequences of night duties (>7 days) produced
cumulative performance decline.

"© 2025 by the Author(s). Published by IJAR under CC BY 4.0. Unrestricted use allowed
with credit to the author."
……………………………………………………………………………………………………....

Corresponding Author:- SiSaid.Meliani

Address:-Radiology Department ,Cheikh Khalifa International University Hospital, Casablanca, 292
Morocco Medicine Faculty, Mohammed VI University of Sciences and HealthUM6SS,Casablanca,
Morocco.
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Conclusions:Experience reduces—but does not eliminate—fatigue-related diagnostic risk. Age-adjusted scheduling,

strengthened teleradiology support, and evidence-based workforce planning are essential to maintain diagnostic
accuracy and patient safety during overnight coverage.

Introduction:-
The radiology workforce increasingly relies on senior, board-certified radiologists to provide overnight coverage,
particularly in teleradiology settings and healthcare facilities where resident coverage is unavailable.¹⁻³ While
extensive research has examined trainee performance during night shifts, the assumption that experienced
radiologists are immune to night shift-related performance degradation remains largely untested.⁴⁻⁶Senior
radiologists face unique challenges during night shifts that differ fundamentally from those affecting trainees. These
include: (1) age-related changes in circadian rhythm adaptability, (2) increased likelihood of interpreting complex
cases without immediate consultation, (3) higher medico-legal responsibility for final interpretations, (4) frequent
work in isolation via teleradiology, and (5) the necessity of balancing night coverage with daytime
responsibilities.⁷⁻⁹ Additionally, the aging radiology workforce—with 35% of practicing radiologists over age 55 in
many countries—raises critical questions about sustainable overnight coverage models.¹⁰⁻¹²

In Morocco, as in many middle-income countries, the radiology workforce is aging without parallel trainee
expansion. Over 40% of senior radiologists are above 55 years, often providing both daytime and overnight
emergency coverage. With increasing adoption of teleradiology and regional centralization of imaging services,
understanding how age, workload, and modality complexity interact under these conditions is critical to sustain
diagnostic accuracy and workforce longevity. Recent high-profile cases involving overnight misinterpretations by
experienced radiologists have highlighted potential vulnerabilities in current coverage models. The shift toward
attending-only overnight coverage in many healthcare systems, driven by requirements for immediate final
interpretations and reduced training programs, makes understanding senior radiologist performance critical for both
patient safety and workforce planning.This systematic review and meta-analysis aims to: (1) quantify diagnostic
performance differences between night and day shifts specifically for senior radiologists, (2) identify factors that
uniquely affect experienced practitioners during overnight work, (3) examine age-related vulnerabilities to night
shift effects, and (4) evaluate contextual modifiers including workload, practice setting, and case complexity

Methods:-
Study Design and Registration:-
This systematic review and meta-analysis adheres to PRISMA 2020 guidelines. PROSPERO registration was not
required, as the review synthesizes previously published diagnostic accuracy data and does not involve patient-level
outcomes. Heterogeneity among studies was quantified using the I² statistic, and publication bias was assessed via
funnel plots and Egger's regression test.

Search Strategy:-
We conducted a systematic search of PubMed/MEDLINE, EMBASE, Web of Science, and the ACR Quality and
Safety Database from January 1, 2000, to December 31, 2024. The 25-year time frame was selected to capture the
modern era of digital radiology and PACS implementation. Search terms included combinations of: (radiology OR
radiologist) AND (attending OR senior OR board-certified OR consultant) AND (night shift OR overnight OR after-
hours) AND (error OR discrepancy OR accuracy OR performance). We specifically excluded studies focusing
primarily on residents or fellows unless they included separate analysis of attending performance.

The complete PubMed search string was:

((radiolog*[Title/Abstract] OR "diagnostic imaging"[MeSH Terms]) AND (attending[Title/Abstract] OR
senior[Title/Abstract] OR "board certified"[Title/Abstract] OR consultant[Title/Abstract] OR
experienced[Title/Abstract] OR "post-training"[Title/Abstract]) AND ("night shift"[Title/Abstract] OR
overnight[Title/Abstract] OR "after-hours"[Title/Abstract] OR "out-of-hours"[Title/Abstract] OR
nocturnal[Title/Abstract] OR "off-hours"[Title/Abstract]) AND (error*[Title/Abstract] OR
discrepanc*[Title/Abstract] OR accurac*[Title/Abstract] OR performance[Title/Abstract] OR "diagnostic
quality"[Title/Abstract] OR misdiagnos*[Title/Abstract]))

Similar search strategies were adapted for EMBASE and Web of Science using their respective controlled
vocabularies. No language restrictions were applied initially. Reference lists of included studies and relevant review

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articles were hand-searched for additional citations. We also consulted with five expert radiologists to identify
unpublished datasets or ongoing studies
.
Inclusion and Exclusion Criteria:-
Studies were included if they: (1) reported diagnostic performance metrics for board-certified radiologists or those
with ≥5 years post-residency experience, (2) included interpretations performed during defined night shifts (any
overnight period between 6 PM and 8 AM), (3) provided quantitative error or discrepancy rates with sufficient data
for meta-analysis, (4) were published in peer-reviewed journals or presented as full conference proceedings with
adequate methodological detail, and (5) were published after January 1, 2000, to reflect contemporary digital
imaging practices.Studies were excluded if they: (1) focused exclusively on radiology residents, fellows, or medical
students without separate attending-level data, (2) examined only interventional procedures without diagnostic
interpretation, (3) lacked clear differentiation between experience levels, (4) reported only qualitative outcomes
without quantifiable error rates, (5) did not specify night shift time periods, or (6) were case reports, editorials, or
reviews without original data.

Study Selection:-
Two reviewers independently screened all titles and abstracts using predefined eligibility criteria programmed into
Covidence systematic review software. Full-text articles of potentially eligible studies were obtained and
independently assessed by both reviewers. Disagreements were resolved through discussion, with arbitration by a
third senior reviewer when consensus could not be reached. Inter-rater agreement for study inclusion was substantial
(Cohen's κ = 0.83).

Definition of Senior Radiologist:-

For this analysis, "senior radiologist" was operationally defined as meeting at least one of the following criteria: (1)
board-certified or board-eligible status in diagnostic radiology by recognized certifying bodies (e.g., American
Board of Radiology, Royal College of Radiologists), (2) minimum 5 years of clinical experience post-residency
completion, (3) designated as attending physician, consultant, or equivalent independent practitioner level, or (4)
explicitly identified by study authors as experienced or senior-level radiologists. When studies included mixed
experience levels, only data specific to senior radiologists were extracted. Age data were collected when available to
conduct age-stratified analyses independent of experience duration.

Data Extraction:-
A standardized data extraction form was developed and pilot-tested on five randomly selected studies. Two
reviewers independently extracted the following variables from each included study: first author, publication year,
country and geographic region, practice setting (academic medical center, community hospital, teleradiology
service, or mixed), study design (prospective vs. retrospective), sample size (total interpretations), number of
participating radiologists, radiologist demographics (mean age, age range, years of experience), imaging modalities
examined, night shift definition (specific hours), error or discrepancy definition and severity classification, error
rates during night shifts, error rates during day shifts (when available), temporal patterns within night shift, factors
associated with errors (age, workload, modality complexity), and any quality improvement interventions
implemented.When studies reported multiple error categories (e.g., minor vs. major discrepancies), we extracted
only clinically significant errors defined as those requiring change in patient management, resulting in diagnostic
revision, or having potential patient safety implications. When necessary, we contacted corresponding authors to
request missing data or clarification of reported outcomes. Response rate to author queries was 67% (12 of 18
studies).

Quality Assessment:-
Methodological quality of included studies was independently assessed by two reviewers using the Newcastle-
Ottawa Scale (NOS) adapted for observational studies in diagnostic accuracy research. The NOS evaluates three
domains: (1) Selection of study participants (representativeness of exposed cohort, selection of non-exposed cohort,
ascertainment of exposure, demonstration that outcome was not present at start of study—maximum 4 points), (2)
Comparability of cohorts on the basis of design or analysis (control for confounders—maximum 2 points), and (3)
Assessment of outcome (independent blind assessment, adequate follow-up length, adequacy of follow-up—
maximum 3 points).Total NOS scores ranged from 0-9, with studies scoring 7-9 classified as high quality, 4-6 as
moderate quality, and 0-3 as low quality. Inter-rater agreement for quality assessment was excellent (intraclass
correlation coefficient = 0.91). No study was excluded based solely on quality score.

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Statistical Analysis:-
All statistical analyses were performed using R software version 4.3.1 (R Foundation for Statistical Computing,
Vienna, Austria) with the meta and metafor packages. We calculated pooled estimates of major discrepancy rates for
night shifts and day shifts separately, as well as odds ratios comparing night versus day performance.Given
anticipated heterogeneity in practice settings, error definitions, and study populations, we employed random-effects
meta-analysis using the DerSimonian-Laird method with Hartung-Knapp adjustment for more conservative
confidence interval estimation. Effect sizes were expressed as odds ratios (OR) with 95% confidence intervals (CI).
Statistical significance was set at two-tailed p < 0.05.

Between-study heterogeneity was quantified using Cochran's Q test and the I² statistic. I² values were interpreted as
follows: 0-40% (might not be important), 30-60% (moderate heterogeneity), 50-90% (substantial heterogeneity), and
75-100% (considerable heterogeneity). When substantial heterogeneity was detected (I² > 50%), we performed pre-
specified subgroup analyses and meta-regression to explore potential sources.Planned subgroup analyses examined:
(1) radiologist age categories (<48 years, 48-52 years, >52 years), (2) practice setting (academic medical center,
community hospital, teleradiology), (3) years of post-training experience (5-10 years, 11-20 years, >20 years), (4)
night shift pattern (occasional call coverage, regular rotating nights, dedicated nocturnist position), (5) geographic
region (North America, Europe, Asia, other), and (6) imaging modality complexity (routine studies vs. complex
subspecialty examinations).Random-effects meta-regression was conducted to assess relationships between
continuous variables (mean age, years of experience, study sample size, publication year) and effect size magnitude.
Sensitivity analyses included: (1) exclusion of teleradiology studies to assess on-site performance separately, (2)
exclusion of studies with moderate quality scores (NOS < 7), (3) leave-one-out analysis to evaluate influence of
individual studies, and (4) restriction to studies published after 2015 to assess contemporary practice
patterns.Publication bias was evaluated through visual inspection of funnel plots and formal statistical testing using
Egger's regression test, with p < 0.10 considered indicative of potential asymmetry.

Ethical Considerations:-
This systematic review and meta-analysis involved secondary analysis of aggregate data from previously published
studies. As no individual patient data were accessed and all included studies had received ethical approval from their
respective institutions, this review did not require separate ethics committee approval per institutional policy and
international guidelines for secondary research (Declaration of Helsinki 2013, Article 23).

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Figure 1. PRISMA 2020 flow diagram showing study selection process. From 1,892 initially identified records
across four databases, 18 studies comprising 203,097 interpretations were included after duplicate removal
and eligibility assessment.

Results:-
Study Selection and Characteristics:
The systematic search identified 1,892 records across all databases. After removing duplicates (n=436), 1,456
records underwent title and abstract screening. Of these, 1,289 were excluded based on predefined criteria, leaving
167 full-text articles for detailed assessment. After full-text review, 149 articles were excluded for specific reasons:
no senior radiologist data (n=67), no quantitative error rates (n=34), unclear night shift definition (n=28),
interventional procedures only (n=12), and insufficient data for extraction (n=8). Ultimately, 18 studies met all
inclusion criteria and were included in the systematic review and meta-analysis. The complete study selection
process is illustrated in the PRISMA flow diagram (Figure 1).

Table 1. Characteristics of included studies (n=18). Studies represent diverse geographic regions and practice
settings, with a total sample of 203,097 interpretations performed by 384 senior radiologists.

The 18 included studies comprised 203,097 interpretations by senior radiologists. Studies represented diverse
practice settings: academic medical centers (n=7, 38.9%), community hospitals (n=5, 27.8%), teleradiology services
(n=4, 22.2%), and mixed settings (n=2, 11.1%). Geographic distribution included North America (n=6), Europe
(n=7), Asia (n=2), South America (n=1), and Oceania (n=2). Mean radiologist age was 49.9 years (range 45.3-55.2),
with average experience of 16.2 years post-training (range 11.3-23.5 years).

Quality Assessment:-
Quality assessment using the Newcastle-Ottawa Scale revealed overall high methodological quality. The mean NOS
score was 7.8 ± 0.9 (range 6-9). Eleven studies (61.1%) achieved excellent quality ratings (NOS 8-9), six studies
(33.3%) were rated as good quality (NOS 6-7), and one study (5.6%) was rated as moderate quality (NOS 6). No
studies were rated as low quality or excluded based on quality assessment. Detailed quality scores for individual
domains and overall ratings are presented in Table 2.

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Table 2. Quality assessment of included studies using Newcastle-Ottawa Scale. Studies demonstrated high
methodological quality with mean NOS score of 7.8 ± 0.9.

Overall Performance Metrics:-

Senior radiologists showed significantly higher error rates during night shifts compared to day shifts. The pooled
major discrepancy rate was 2.03% (95% CI: 1.71-2.35%) for night shifts versus 1.32% (95% CI: 1.09-1.55%) for
day shifts, representing a 56% increase in odds of error (OR 1.56, 95% CI: 1.49-1.62, p<0.001). Moderate
heterogeneity was observed across studies (I²=68.4%, τ²=0.043). While this relative increase is comparable to that
observed in resident studies, the absolute error rates were approximately 40% lower than trainee rates, confirming
the protective effect of experience.

Figure 2. Forest plot showing night shift versus day shift error rates among senior radiologists. Random-
effects pooled OR of 1.56 (95% CI: 1.49-1.62, p<0.001) indicates significantly higher error rates during night
shifts. Moderate heterogeneity (I²=68.4%) was observed across studies.

Age-Related Vulnerabilities:-
Meta-regression revealed significant age-related effects on night shift performance (p=0.023 for subgroup
differences). Radiologists aged >52 years showed greater night-day performance differential (OR 1.78, 95% CI:
1.43-2.22) compared to those aged <48 years (OR 1.32, 95% CI: 1.08-1.59). The intermediate age group (48-52
years) demonstrated OR of 1.58 (95% CI: 1.34-1.86). The age effect was most pronounced after 2 AM, with
radiologists >52 years showing 2.3-fold increased errors between 2-6 AM compared to their daytime baseline,
versus 1.5-fold for younger colleagues. Recovery time after night shifts also increased with age, with those >52
years requiring an average of 2.8 days to return to baseline performance versus 1.4 days for those <48 years.

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Figure 3. Age-stratified subgroup analysis of night shift error rates. Older radiologists (>52 years)
demonstrated significantly higher vulnerability to night shift effects compared to younger colleagues (test for
subgroup differences: p=0.023).

Temporal Patterns Within Night Shifts:-

Senior radiologists showed better preservation of performance during early night hours (10 PM-2 AM) with error
rates of 1.42% versus 1.31% daytime baseline (p=0.18). However, performance deteriorated significantly after 2
AM: 2-4 AM (2.03%, +41% vs baseline, p<0.001), 4-6 AM (2.41%, +63% vs baseline, p<0.001), and 6-8 AM
(2.67%, +79% vs baseline, p<0.001). This pattern suggests that experience provides some buffer against early
fatigue but cannot overcome fundamental circadian rhythm disruption during early morning hours when circadian
pressure for sleep is strongest.

Practice Setting and Coverage Models:-

Teleradiology Performance:-
Teleradiology settings showed significantly higher error rates than on-site coverage. Night shift error rates were
2.31% (95% CI: 1.89-2.73%) for teleradiology versus 1.68% (95% CI: 1.41-1.95%) for on-site coverage (p<0.01).
Factors contributing to this difference included: lack of access to prior imaging (cited in 43% of errors), inability to
obtain clinical context (38%), technical issues with image quality (27%), and isolation from collegial consultation
(24%). Senior radiologists working from home showed intermediate performance (1.94% error rate), suggesting
partial mitigation of isolation effects.

Workload and Case Complexity:

Senior radiologists handled more complex cases during night shifts, with 67% reporting regular interpretation of
subspecialty studies outside their primary expertise. Error rates increased non-linearly with workload: <20
studies/shift (1.51%), 20-40 studies (1.73%), >40 studies (2.84%, p<0.001 vs <20). The workload effect was more
pronounced for radiologists >50 years old, suggesting age-workload interaction. Complex procedures (CT
angiography, MR neuroimaging) showed 3.1-fold higher error rates at night versus day, compared to 1.4-fold for
routine studies.

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Consecutive Night Shift Effects:

Unlike residents who showed adaptation after 3-6 consecutive nights, senior radiologists showed progressive
performance decline with consecutive night shifts. Error rates by consecutive night were: nights 1-3 (1.72%), nights
4-6 (1.91%), nights 7+ (2.43%, p<0.001 versus nights 1-3). This finding suggests that while younger individuals can
partially adapt to night schedules, older radiologists may accumulate sleep debt without adequate recovery. The
effect was most pronounced in radiologists >52 years working >7 consecutive nights (error rate 3.12%).

Publication Bias Assessment:-

Visual inspection of the funnel plot showed relatively symmetric distribution of studies around the pooled effect
estimate. Egger's regression test for funnel plot asymmetry yielded p=0.145, indicating no significant publication
bias. Trim-and-fill analysis suggested 2-3 potentially missing studies, though inclusion of these imputed studies did
not materially change conclusions (adjusted OR 1.52, 95% CI 1.45-1.59).

Figure 4. Funnel plot for assessment of publication bias. Egger's regression test showed no significant
asymmetry (p=0.145), suggesting minimal publication bias. Individual studies are represented by circles;
pseudo 95% confidence limits are shown as dashed lines.

Discussion:-
This meta-analysis provides the first comprehensive examination of night shift effects specifically on senior
radiologists, revealing important vulnerabilities that persist despite extensive experience. While senior radiologists
maintain lower absolute error rates than trainees, the 56% increase in odds of error during night shifts represents a
substantial patient safety concern, particularly given that these are typically final interpretations without subsequent
review.

Physiological and Cognitive Mechanisms:

The observed age-related increase in night shift vulnerability likely reflects multiple intersecting physiological
mechanisms related to circadian rhythm regulation and cognitive aging. The suprachiasmatic nucleus, which
governs circadian timing, shows age-related neuronal loss and reduced amplitude of circadian gene expression,
diminishing the ability to phase-shift in response to altered sleep-wake schedules. Older adults demonstrate earlier
circadian phase preferences (advanced sleep phase), making adaptation to late-night wakefulness particularly
challenging. Additionally, aging is associated with reduced sleep efficiency, decreased slow-wave sleep, and more
fragmented sleep architecture, impairing the restorative quality of daytime sleep following night shifts and leading
to cumulative sleep debt.

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From a cognitive perspective, the observed performance patterns reflect differential effects of fatigue on distinct
cognitive domains. While crystallized intelligence and pattern recognition—strengths that increase with radiologic
experience—remain relatively preserved during mild-to-moderate fatigue, executive functions such as sustained
attention, working memory, and cognitive flexibility show earlier and more pronounced deterioration. These
executive functions are disproportionately affected by both circadian misalignment and aging, explaining why even
highly experienced radiologists show vulnerability during early morning hours (2-6 AM) when circadian pressure
for sleep is strongest. The increased error rates for complex cases requiring integration of multiple imaging
sequences or subspecialty expertise likely reflect this specific impairment in executive cognitive domains, as these
tasks demand higher-order processing beyond pure pattern recognition skills.

Age-Related Vulnerability and Workforce Implications:

The age-related vulnerability to night shift effects challenges current workforce models that increasingly rely on
older radiologists for overnight coverage. The finding that radiologists over 52 years show 78% increased odds of
error at night, combined with progressive deterioration over consecutive nights, suggests urgent need for age-
adapted scheduling. This is particularly concerning given workforce demographics, with the median age of
practicing radiologists now exceeding 50 years in many countries and expected to continue rising as the workforce
ages without commensurate trainee expansion.

The paradoxical lack of adaptation with consecutive night shifts distinguishes senior radiologists from residents.
While younger trainees show some physiological adaptation after 3-6 consecutive nights, experienced radiologists
demonstrate cumulative performance decline. This likely reflects age-related reduction in circadian plasticity and
increased susceptibility to sleep debt accumulation, necessitating different scheduling approaches than those
developed for resident coverage.

Teleradiology and Environmental Factors:

The teleradiology findings have significant implications for evolving practice models. The 37% higher error rate in
teleradiology settings compared to on-site coverage suggests that isolation and lack of clinical context compound the
biological challenges of night work. As healthcare systems increasingly adopt remote overnight coverage to address
workforce shortages, these findings highlight need for enhanced support systems, including improved access to
clinical information, prior imaging, and collegial consultation mechanisms.The intermediate error rate observed in
home-based hybrid models suggests that physical isolation may be less critical than informational isolation.
Interventions should focus on ensuring robust access to electronic health records, prior studies, and real-time
communication channels rather than necessarily requiring on-site presence. However, the substantially higher error
rates in pure teleradiology settings with limited clinical integration underscore the importance of comprehensive
clinical context for diagnostic accuracy.

Clinical and Policy Implications:

These findings support several evidence-based recommendations for optimizing senior radiologist night coverage:
1. Age-Stratified Scheduling
Radiologists >52 years should have limited consecutive night shifts (maximum 3-4 nights), reduced overnight
workload caps (targeting <30 complex studies per shift), and longer recovery periods between night rotations
(minimum 48-72 hours). Healthcare systems should consider transitioning senior radiologists to evening coverage (6
PM-midnight) rather than full overnight shifts, leveraging their expertise during hours when they can maintain peak
performance while providing coverage extension.

2. Enhanced Teleradiology Support

Implementation of structured communication protocols with on-site teams, ensuring robust access to prior imaging
and clinical data through integrated electronic health records, providing real-time consultation capabilities with
subspecialists through secure messaging or video platforms, and considering hybrid models with on-site support for
complex cases can mitigate isolation effects and improve diagnostic accuracy.

3. Complexity-Based Triage
Reserve complex subspecialty interpretations for daytime when possible, implement AI-assisted triage to identify
high-risk studies requiring enhanced scrutiny, establish clear protocols for deferring non-urgent complex studies to
daytime subspecialty review, and develop decision support systems that alert radiologists to high-risk scenarios
during vulnerable hours.

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4. Nocturnist Models
Consider dedicated nocturnist positions for radiologists who self-select and demonstrate resilience to night work,
with appropriate compensation differentials (typically 20-30% premium) and career advancement pathways to
ensure sustainability. Regular rotation of nocturnists back to daytime practice every 6-12 months can help prevent
burnout and maintain diagnostic skills across the full spectrum of cases.

5. Quality Assurance Programs

Implement targeted peer review of overnight interpretations, particularly for radiologists >52 years and those in
teleradiology settings. Use performance metrics to identify individuals who may benefit from schedule
modifications or additional support. Establish systematic overnight discrepancy review conferences to identify
system-level issues and opportunities for improvement.

Relevance for Morocco and Similar Healthcare Systems:

These findings have direct relevance for Morocco and similar healthcare systems experiencing concurrent workforce
aging and infrastructure modernization. National hospital networks could adopt age-stratified night scheduling
policies, implement caps on consecutive night duties (e.g., maximum 4 consecutive nights for radiologists >52
years), and establish recovery intervals aligned with occupational health standards.The Moroccan Society of
Radiology (SMR) could develop a 'Radiology Fatigue Charter' parallel to those used in anesthesia and aviation
safety, incorporating evidence-based scheduling recommendations and fatigue risk management principles. Regional
teleradiology networks, increasingly common in Morocco's centralized healthcare system, should prioritize
implementation of robust clinical integration platforms and decision support tools to mitigate isolation effects.
AI-based triage systems could be deployed to prioritize complex studies during vulnerable circadian hours, routing
high-risk cases to younger radiologists or deferring non-urgent complex studies to daytime subspecialty review.
Such systems could be particularly valuable in settings with limited subspecialty availability during night hours.

Limitations:-
This review has several important limitations that warrant consideration. First, substantial heterogeneity existed in
how errors and discrepancies were defined across included studies. While all studies reported clinically significant
errors, some used change in patient management as the threshold, others defined errors based on diagnostic revision,
and still others employed expert panel review with varying consensus criteria. This variability in error classification
likely contributed to the moderate statistical heterogeneity observed (I² = 68.4%) and may affect the precision of
pooled estimates. However, sensitivity analyses restricted to studies using similar error definitions showed
consistent effect directions, supporting the robustness of our main findings.

Second, we lacked individual-level data on factors that could significantly influence night shift performance,
including radiologist health status, presence of sleep disorders (e.g., sleep apnea, insomnia), medication use,
chronotype preferences (morning/evening preference), commute distance for on-site coverage, and baseline sleep
quality. These unmeasured variables may confound the observed age-performance relationships and limit our ability
to identify radiologists at highest risk for night shift errors. Future studies incorporating wearable sleep monitoring
devices (actigraphy) and validated fatigue assessment tools would provide more granular insights into individual
vulnerability factors.

Third, the included studies predominantly originated from academic medical centers (39%) and larger healthcare
systems with established quality assurance programs. Community hospitals and smaller practices may be
underrepresented, potentially limiting generalizability to diverse practice environments. Academic centers often
have different case mix complexity, availability of subspecialty expertise, and quality monitoring infrastructure
compared to community settings, which could influence both baseline performance and the magnitude of night shift
effects.

Fourth, teleradiology studies demonstrated inconsistent reporting of radiologist working conditions, including
whether interpretations were performed from home versus dedicated reading centers, availability of technical
support, quality of internet connectivity, and access to prior imaging studies and clinical information. This
heterogeneity within the teleradiology subgroup (I² = 71.2%) suggests that remote coverage models vary
substantially in their implementation and support infrastructure, making it difficult to draw definitive conclusions
about optimal teleradiology practices for night coverage.

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Fifth, publication bias represents a potential concern, as institutions with established peer review systems and quality
improvement initiatives may be more likely to publish discrepancy data than those without systematic monitoring.
While our funnel plot analysis and Egger's test did not reveal significant asymmetry (p = 0.14), the possibility of
selective reporting cannot be entirely excluded. Additionally, positive findings (i.e., significant night-day
differences) may be more likely to be published than null results, potentially inflating the pooled effect size.
Sixth, selection bias may affect our results if radiologists experiencing particular difficulty with night shift work
preferentially withdrew from overnight coverage or transitioned to daytime-only positions. This "healthy worker
effect" could lead to underestimation of true night shift impacts, as our included studies would predominantly
capture radiologists who tolerated night work well enough to continue performing it. Longitudinal studies tracking
radiologists over time would help quantify this potential bias.

Seventh, our analysis provides limited subspecialty-specific insights, as most studies reported aggregate data across
multiple imaging modalities rather than detailed performance metrics for individual subspecialties (e.g.,
neuroradiology, cardiothoracic imaging, musculoskeletal imaging). The impact of night shifts may vary
considerably across subspecialties based on case complexity, frequency of urgent findings, and degree of
subspecialty training required, suggesting a need for more granular subspecialty-focused research.

Eighth, we found insufficient data on the effectiveness of specific interventions to mitigate night shift performance
decline in senior radiologists. While our recommendations are based on observed risk factors and general principles
of fatigue management derived from other healthcare settings and aviation, most are not yet supported by rigorous
intervention studies in this specific population. The evidence base would benefit from randomized controlled trials
evaluating age-adapted scheduling, decision support tools, and other countermeasures specifically for experienced
radiologists.

Ninth, none of the included studies reported long-term health outcomes associated with night shift work in senior
radiologists, such as cardiovascular disease, metabolic disorders, or mental health impacts. Understanding these
broader health effects is essential for developing sustainable workforce models that balance immediate patient care
needs with long-term radiologist wellbeing and career longevity.

Finally, our meta-regression analyses had limited statistical power to detect small effect modifications due to the
relatively small number of included studies (n=18). Age-by-workload interactions and other complex relationships
may exist but could not be adequately explored with the available data. Larger collaborative databases pooling
individual-level data from multiple institutions would enable more sophisticated analyses of effect modifiers and
risk stratification.

Future Research Directions:-

Several areas warrant further investigation to strengthen the evidence base for optimizing senior radiologist night
coverage. Development of validated screening tools to identify radiologists at higher risk for night shift errors,
incorporating age, chronotype assessment, sleep disorder screening, and health factors, would enable personalized
scheduling approaches. Evaluation of pharmacological and non-pharmacological interventions tailored to older
healthcare workers, including controlled trials of bright light therapy, strategic napping protocols, and melatonin
supplementation with objective performance outcomes, could identify effective countermeasures.

Economic analysis of different coverage models balancing quality, safety, and workforce sustainability is needed to
inform resource allocation decisions. Investigation of AI-assisted interpretation specifically during vulnerable hours
could determine whether decision support tools can mitigate cognitive impairment during early morning hours.
Longitudinal studies examining cumulative effects of night work on radiologist health and career longevity would
provide essential data for workforce planning and occupational health policies.

Multi-site studies incorporating diverse practice settings, particularly community hospitals and rural facilities, would
enhance understanding of how practice environment modulates night shift effects and inform setting-specific
interventions. Subspecialty-focused research examining performance patterns across different imaging domains
(neuroradiology, body imaging, cardiac imaging) could enable tailored approaches recognizing differential
vulnerability across specialties.

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ISSN:(O) 2320-5407, ISSN(P) 3107-4928 Int. J. Adv. Res. 13(11), November-2025, 292-303

Conclusions:-
Senior radiologists, while maintaining lower absolute error rates than trainees, show clear vulnerability to night shift
effects that increase with age and consecutive night exposure. The 56% increase in diagnostic errors during night
shifts, combined with age-related susceptibility and challenges in teleradiology settings, necessitates fundamental
reconsideration of overnight coverage models.

As the radiology workforce ages and healthcare systems increasingly rely on experienced practitioners for 24/7
coverage, evidence-based scheduling that accounts for age-related circadian vulnerabilities becomes essential for
maintaining diagnostic quality and patient safety. These findings challenge the assumption that experience alone
mitigates night shift risks and highlight the need for system-level interventions tailored to senior radiologist
capabilities and limitations.

Implementation of age-adapted scheduling (limiting consecutive nights, providing extended recovery periods,
considering evening vs. overnight shifts for older radiologists), enhanced support for remote coverage (robust
clinical integration, decision support tools, subspecialty consultation access), and strategic deployment of emerging
technologies (AI-assisted triage, automated quality assurance) represent critical steps toward sustainable and safe
overnight radiology services.

Future workforce planning must balance the expertise of senior radiologists with recognition of their increased
vulnerability to circadian disruption, particularly as demographic shifts continue to reshape the radiology workforce.
The development of evidence-based policies addressing these vulnerabilities is not only a patient safety imperative
but also essential for maintaining a sustainable, healthy, and productive radiology workforce capable of providing

Conflicts Of Interest:-
The authors declare no conflicts of interest related to this work.

Funding:-
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.

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