Neurohospitalists Enhance Resident Perception of the Educational and Clinical Value of a Night Float Rotation

Abstract

Background and Purpose: Neurology residency training programs have been profoundly impacted by recent changes in resident duty hours, workloads, and supervisory requirements. In response, many programs have adopted a night float coverage system to minimize the requirements for overnight call. The majority involves residents working a block of night shifts in what is typically a service-oriented rotation. Recently, concerns have arisen regarding the impact of this design on resident education and patient care. We have developed a novel on-site nighttime neurohospitalist model for the explicit purpose of steepening the initial learning curve for neurology residents in an effort to rapidly improve their neurological skills and, in conjunction, overnight patient care. We surveyed residents after the initiation of this system to assess their perception of the impact of direct overnight supervision on education and patient care. Methods: As part of ongoing quality improvement efforts, surveys were administered to neurology house staff at a tertiary academic medical center after they had completed service on the night float rotation both with and without an attending in the hospital using a retrospective pre/postdesign. Results: There was a robust positive impact on resident's perception of overall quality, educational value, and clinical quality on the night float rotation with an attending onsite. Despite an overall perception that their autonomy was maintained, residents believed barriers to contact the attending were lower, and attending interaction during critical decision making was more frequent. Conclusions: Direct overnight supervision by a neurohospitalist enhances the educational value and care quality on overnight resident rotations.Keywords residency, education, night float, supervision, autonomy, neurohospitalist, quality Residency training programs have been profoundly impacted by restrictions on resident duty hours, workloads, and supervisory requirements implemented by the Accreditation Council for Graduate Medical Education over the past decade, and neurology residencies are no exception. In response, many programs have undergone substantial changes in design and schedule; most have adopted a night float coverage system to minimize requirements for overnight call and comply with duty hour restrictions. Although there are a variety of models in practice, the majority involves residents working a block of night shifts to cover consultations, admissions, and urgent issues for established inpatients. 1-4Night float is typically a service-oriented rotation with selfguided learning being the norm and opportunities for attending interaction and patient follow-up limited to phone contact. Although these systems decrease continuous and total work hours for residents, concerns have been raised regarding their impact on resident education and the quality of patient care delivered. 5-11Since more stringent duty hour restrictions for interns (postgraduate year 1 [PGY-1]) were enacted in 2010, firstyear neu...

Resident Autonomy

“…Traditionally the highest levels of autonomy have been experienced by residents during overnight shifts when there were typically few, if any, attending physicians in the hospital [14,34,35]. With the increasing expectations for resident supervision and the decrease in resident work hours, over the last 15 years, the implementation of 24-hour coverage by hospitalists has become more common, resulting in a decrease in resident experience managing patients without direct supervision immediately available; however, this is not uniformly rated by residents as being detrimental to their education [35,36].…”

“…Traditionally the highest levels of autonomy have been experienced by residents during overnight shifts when there were typically few, if any, attending physicians in the hospital [14,34,35]. With the increasing expectations for resident supervision and the decrease in resident work hours, over the last 15 years, the implementation of 24-hour coverage by hospitalists has become more common, resulting in a decrease in resident experience managing patients without direct supervision immediately available; however, this is not uniformly rated by residents as being detrimental to their education [35,36]. Another time-honored practice for promoting resident autonomy is the continuity clinic, which has been (and in many cases continues to be) a common part of training for pediatric [37], internal medicine [38], neurology [39], obstetrics and gynecology [40], and even ophthalmology [41] residencies.…”

Collaborative Comanagement Between Neurohospitalists and Internal Medicine Hospitalists Decreases Provider Costs and Enhances Satisfaction With Neurology Care at an Academic Medical Center

“…Yearly response rate was between 38% and 47%. Each year approximately 20 referring providers responded (20,23,20, and 19 for 2013, 2014, 2015, and 2016, respectively), about half from emergency medicine and half from hospital medicine.…”

Defining the Role of the Academic Neurohospitalist in Residency Education

“…20 Increased ''ward time'' for faculty members has not been associated with any perceived loss of autonomy in medicine or neurology. 23,24 Concerns regarding the hospitalist model have been shown to diminish with experience on the service, and resident opinion that a hospitalist service limits autonomy inappropriately has been rare. 19 There is a theoretical risk to future patients by not providing trainees the chance to make independent decisions in the relatively protected environment of a residency program.…”

“…[23][24][25][26][27] In particular, more frequent direct supervision after hours may take advantage of a rich and usually untapped educational opportunity, and presence of attending physician in the hospital has been shown to improve both resident and attending perceptions of the educational value of night rotations in both medicine and neurology. 23,[25][26][27] In addition, residents' presence on inpatient service is often fragmented by obligations to continuity clinics and didactic teaching sessions; an available neurohospitalist can help to ameliorate the stress that comes with these conflicting responsibilities. It is relevant to note that increased attending availability improved resident satisfaction whether or not attending physicians defined themselves as ''hospitalists'' per se.…”