Association Between Nocturnist Supervision and Perceived Overnight Supervision Adequacy Among Internal Medicine Residents in the US | Medical Education and Training | JAMA | JAMA Network
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Table 1.  Characteristics of Respondentsa
Characteristics of Respondentsa
Table 2.  Perception of Adequacy of Supervision to Ensure Patient Safety Overnight
Perception of Adequacy of Supervision to Ensure Patient Safety Overnight
1.
Farnan  JM, Burger  A, Boonyasai  RT,  et al; SGIM Housestaff Oversight Subcommittee.  Survey of overnight academic hospitalist supervision of trainees.   J Hosp Med. 2012;7(7):521-523. doi:10.1002/jhm.1961PubMedGoogle ScholarCrossref
2.
Hundert  SA, White  AA, Reilly  DF.  Number of general medicine hospital admissions performed by internal medicine residents before and after the 2011 duty-hour regulations.   South Med J. 2015;108(8):476-481.PubMedGoogle Scholar
3.
Clark  AV, LoPresti  CM, Smith  TI.  Trends in inpatient admission comorbidity and electronic health data: implications for resident workload intensity.   J Hosp Med. 2018;13(8):570-572. doi:10.12788/jhm.2954PubMedGoogle Scholar
4.
Blum  AB, Shea  S, Czeisler  CA, Landrigan  CP, Leape  L.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.   Nat Sci Sleep. 2011;3:47-85.PubMedGoogle Scholar
5.
Trowbridge  RL, Almeder  L, Jacquet  M, Fairfield  KM.  The effect of overnight in-house attending coverage on perceptions of care and education on a general medical service.   J Grad Med Educ. 2010;2(1):53-56. doi:10.4300/JGME-D-09-00056.1PubMedGoogle ScholarCrossref
6.
Brotherton  SE, Etzel  SI.  Graduate medical education, 2017-2018.   JAMA. 2018;320(10):1051-1070. doi:10.1001/jama.2018.10650PubMedGoogle ScholarCrossref
Research Letter
April 14, 2020

Association Between Nocturnist Supervision and Perceived Overnight Supervision Adequacy Among Internal Medicine Residents in the US

Author Affiliations
  • 1Department of Medicine, George Washington University, Washington, DC
  • 2Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
  • 3Alliance for Academic Internal Medicine, Alexandria, Virginia
  • 4American College of Physicians, Philadelphia, Pennsylvania
  • 5Department of Medicine, Medical College of Wisconsin, Milwaukee
JAMA. 2020;323(14):1407-1409. doi:10.1001/jama.2020.0875

Overnight supervision of internal medicine residents has traditionally been indirect1 and provided by a physician outside the hospital. During the past 15 years, the complexity and volume of overnight inpatient medical services have increased.2,3 This, coupled with data that increased resident supervision is associated with improved patient safety,4 has led many teaching hospitals to employ hospitalists in-house overnight (nocturnists).1,5

Little is known about the national landscape of resident overnight supervision, including how commonly internal medicine residency programs use nocturnists and how they affect residents’ supervision. We tested whether residents in programs with nocturnists perceived nighttime supervision differently than those in programs without nocturnists.

Methods

The American College of Physicians Internal Medicine In-Training Examination (IM-ITE) includes a voluntary survey. The 2017 survey asked residents, “How often do you receive adequate supervision to ensure patient safety when you are working overnight?” using a 5-point Likert scale (responses of “always,” “most of the time,” “sometimes,” “rarely,” or “never”). Presence or absence of nocturnists was determined by a yes or no response to “Does your internal medicine residency program have an attending physician who stays in the hospital overnight and is responsible for directly supervising internal medicine residents providing care on medicine wards?”

This analysis was confined to residents in US programs. Because patient safety is a minimum standard of supervision, we used Pearson χ2 or adjusted Wald χ2 statistics to compare the “always” response for receiving adequate supervision with all other responses in respondents with and without nocturnists, with an α level of P ≤ .05. We also performed group-based hypothesis testing among all responses using the Pearson χ2 statistic. Because senior residents may supervise their juniors, we conducted analyses overall and stratified by postgraduate year using the adjusted Wald χ2 statistic and the Kendall τb correlation coefficient interacting presence or absence of nocturnist and postgraduate year with all responses and an α level of P ≤ .01. The data analysis was conducted in Stata SE version 14.2 (StataCorp).

This study was declared exempt by the George Washington University institutional review board.

Results

Of 24 620 internal medicine residents in US programs who completed the IM-ITE in 2017, 23 553 participated in the survey. After excluding 2809 residents who did not allow their data to be used for research purposes, responses from 20 744 internal medicine residents (84% response rate) were analyzed (Table 1). Fifty-six percent were male and 86.1% were residents in categorical programs, with no differences between respondents with nocturnists and without nocturnists.

Overall, 51.4% of respondents reported that their supervision at night was “always” adequate to ensure patient safety, 31.9% responded “most of the time,” 10.6% responded “sometimes,” 4.4% responded “rarely,” and 1.7% responded “never” (Table 2). Fifty-three percent of residents reported having a nocturnist. Significantly more residents who reported having a nocturnist reported “always” receiving adequate supervision to ensure patient safety overnight compared with residents who reported not having a nocturnist (61.3% vs 40.5%, respectively; P < .001). The results for residents having a nocturnist vs not having a nocturnist were statistically significant when “always” vs all other responses were compared and when all response categories were compared. Results were similar by postgraduate year (Table 2).

Discussion

Fifty-one percent of internal medicine residents reported that their overnight supervision was always adequate to ensure patient safety. When nocturnists were present, more residents (61%) reported always receiving adequate supervision than when they were not (40%). However, a substantial percentage did not report always receiving adequate supervision despite having a nocturnist, possibly reflecting variability in nocturnist job descriptions across institutions. Some nocturnists provide care independently while being available for indirect supervision, whereas others primarily provide direct supervision.1,5

Strengths of this study include its large size, high response rate, and capture of a substantial majority of US internal medicine residents. Limitations include measurement of perception rather than objective data and cross-sectional survey design. Program characteristics (eg, university-based or community-based) were not collected and confounding due to program-level variability is possible. These data do not account for other factors that may affect perceived supervision, including safety culture and other personnel.

Hospitals should assess adequacy of their nighttime supervision of residents to ensure patient safety. Best practices for roles of nocturnists merit further study.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: January 22, 2020.

Corresponding Author: Jillian S. Catalanotti, MD, MPH, Medical Faculty Associates, Division of General Internal Medicine, George Washington University, 2150 Pennsylvania Ave NW, Ste 5-416, Washington, DC 20037 (jcatalanotti@mfa.gwu.edu).

Author Contributions: Mr Kisielewski had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Catalanotti, O’Connor.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Catalanotti, O’Connor, Kisielewski, Fletcher.

Critical revision of the manuscript for important intellectual content: O’Connor, Kisielewski, Chick, Fletcher.

Statistical analysis: Catalanotti, O’Connor, Kisielewski, Fletcher.

Administrative, technical, or material support: O’Connor, Kisielewski, Chick.

Supervision: Chick.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the American College of Physicians for including our survey questions on the 2017 Internal Medicine In-Training Examination resident survey and sharing the data with us for analysis. We also thank the Alliance for Academic Medicine and the Association of Program Directors in Internal Medicine survey committee for its assistance with editing the survey questions.

References
1.
Farnan  JM, Burger  A, Boonyasai  RT,  et al; SGIM Housestaff Oversight Subcommittee.  Survey of overnight academic hospitalist supervision of trainees.   J Hosp Med. 2012;7(7):521-523. doi:10.1002/jhm.1961PubMedGoogle ScholarCrossref
2.
Hundert  SA, White  AA, Reilly  DF.  Number of general medicine hospital admissions performed by internal medicine residents before and after the 2011 duty-hour regulations.   South Med J. 2015;108(8):476-481.PubMedGoogle Scholar
3.
Clark  AV, LoPresti  CM, Smith  TI.  Trends in inpatient admission comorbidity and electronic health data: implications for resident workload intensity.   J Hosp Med. 2018;13(8):570-572. doi:10.12788/jhm.2954PubMedGoogle Scholar
4.
Blum  AB, Shea  S, Czeisler  CA, Landrigan  CP, Leape  L.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.   Nat Sci Sleep. 2011;3:47-85.PubMedGoogle Scholar
5.
Trowbridge  RL, Almeder  L, Jacquet  M, Fairfield  KM.  The effect of overnight in-house attending coverage on perceptions of care and education on a general medical service.   J Grad Med Educ. 2010;2(1):53-56. doi:10.4300/JGME-D-09-00056.1PubMedGoogle ScholarCrossref
6.
Brotherton  SE, Etzel  SI.  Graduate medical education, 2017-2018.   JAMA. 2018;320(10):1051-1070. doi:10.1001/jama.2018.10650PubMedGoogle ScholarCrossref
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