Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents

Use of Chart-Stimulated Recall to Explore Uncertainty in Medical Decision-Making Among Senior Internal Medicine Residents

BACKGROUND

Uncertainty is common and impacts both patients and clinicians. The approach to uncertainty in medical trainees may be distinct from that of practicing clinicians and has important implications for medical education.

OBJECTIVE

Describe trainee approach to uncertainty with the use of chart-stimulated recall (CSR)-based interviews, as well as the utility of such interviews in promoting reflection about decision-making among senior internal medicine (IM) residents.

DESIGN

Qualitative analysis of CSR-based interviews with IM residents.

PARTICIPANTS

Senior IM residents rotating on inpatient night float at the University of Pittsburgh Medical Center from February to September 2019.

INTERVENTION

Each participant completed one, 20-min CSR session based on a self-selected case in which there was uncertainty in decision-making. Interviews explored the sources of, approaches to, and feelings about uncertainty.

APPROACH

Two independent coders developed a codebook and independently coded all transcripts. Transcripts were then analyzed using thematic analysis.

KEY RESULTS

The perceived acuity of the patient presentation was the main driver of the approach to and stress related to uncertainty. Perceived level of responsibility in resolving uncertainty during the overnight shift also varied among individual participants. Attending expression of uncertainty provided comfort to residents and alleviated stress related to uncertainty. Residents felt comfortable discussing their uncertainty and felt that the opportunity to think aloud during the exercise was valuable.

CONCLUSIONS

Our study demonstrated a novel approach to the exploration of uncertainty in medical decision-making, with the use of CSR. Variations in resident perceived level of responsibility in resolving uncertainty during the overnight shift suggest a need for curriculum development in approach to uncertainty during night shifts. Though residents often experienced stress related to uncertainty, attending expression of uncertainty was an important mitigator of that stress, emphasizing the important role that the trainee-attending interaction plays in the diagnostic process.

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit

Background

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight.

Objective

What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being?

Methods

A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction.

Results

Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education.

Conclusion

As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

The scope of hospital medicine practice at night: a national survey of night shift hospitalists

Introduction: Although in-person hospitalist presence, increasingly staffed by dedicated nocturnists, has become the norm overnight in the hospital, the scope of nocturnist practice and typical workload has not been defined. This study examines the clinical responsibilities and patient safety perceptions of hospitalists who work night shifts in the United States.Methods: In the fall of 2019, a cross-sectional, web-based survey was administered to physician and nurse practitioner/physician assistant (NP/PA) hospitalists who work night shifts. The questionnaire assessed night staffing structure, typical responsibilities, patient volume, perceptions of safety overnight, as well as demographic information. The survey was posted on the Society of Hospital Medicine (SHM) Hospital Medicine Exchange (HMX) Online Discussion Forum. Additionally, the survey was distributed by 'snowball method' by respondents to other night hospitalists. Responses were collected anonymously.Results: Of the 167 respondents, 157 reported working night shifts. There was at least one respondent from 32 different states. In addition to performing admissions to medicine services and covering inpatients, night hospitalists cover ICU patients, participate in RRT/Code teams and procedure teams, perform consults, participate in medical education, and take outpatient calls. Across institutions, there was a large distribution in numbers of patients covered in a night shift; however, patient volume fell into typical ranges: 5-10 admissions for physicians, 0-6 admissions for NP/PAs, and 25-75 patient cross-coverage census. When physicians perform more than five admissions per night, hospitalists were less likely to agree that they could provide safe care (88% vs. 63%, p = 0.0006).Conclusions: This is the first national study to examine the clinical responsibilities of hospitalists working overnight. Overnight responsibilities are heterogeneous across institutions. As hospitals are increasingly employing nocturnists, more research is needed to guide night staffing and optimize patient safety.