The Effect of Overnight In-House Attending Coverage on Perceptions of Care and Education on a General Medical Service

Abstract

The prevailing model of graduate medical education has long been one of according the trainee increasing gradations of responsibility over time. 1,2 This process remains widely endorsed 3,4 and, despite a lack of substantial empirical evidence supporting its effectiveness, has a strong theoretical basis. 5 It is clear that the degree and quality of the clinical supervision currently provided is highly variable. 2,6,7 In addition, recent developments have highlighted the need to reconsider the current paradigm of supervision. Evolution of the concept of patient safety, for example, has emphasized the importance of preventing medical errors and the need for close oversight of all medical trainees. 8,9 The 2008 report of an Institute of Medicine committee on resident duty hours strongly endorsed greater supervision of residents stating ''The committee found that closer supervision leads to fewer errors, lower patient mortality, and improved quality of care.'' 10 Finally, there has been increased scrutiny as to the specific form of clinical supervision provided, with the acknowledgment that such oversight may occur on several different levels 11 and that direct supervisory involvement in patient care may be the most critical element of effective clinical supervision. 12A logical response on the part of academic medical centers to these developments is to increase attending physician availability and supervision, including mandating 24-hour in-house coverage. As described previously, the potential benefits of a system of increased attending involvement include the prevention of medical errors, more efficient medical care, and decreased length of stay.10 In addition, increased attending presence could serve to counter the ''hidden curriculum,'' which substantially affects resident perceptions of supervision and may act as a barrier to requesting assistance, even when it is clearly necessary. 13,14Yet there are theoretical risks to such a system. Most important, there is the potential to undermine resident autonomy, 6,15 long thought to be integral to the learning process in graduate medical education and a central component of residency program requirements. AbstractBackground An increased emphasis on patient safety has led to calls for closer supervision of medical trainees.It is unclear what effect an increased degree of faculty presence will have on educational and clinical outcomes. The aim of this study was to evaluate resident and attending attitudes and preferences regarding overnight attending supervision.

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

“…Trowbridge et al reported that nearly all residents and attendings preferred an on-site direct supervision model of night float to indirect supervision by phone. 15 Both residents and attendings believed that patient care was improved, with fewer errors and better efficiency; both the groups also felt that education was better with direct supervision. Haber et al reported increases in resident perception of clinical and educational value of night float without a decrement in autonomy.…”

“…Additionally, a positive attitude and perception of value are thought to be very important for learning, and these were clearly improved by direct supervision overnight. [11][12][13]15 Figure 1. Neurology resident perceptions of educational and clinical value of night float rotation are improved by an on-site neurohospitalist.…”

Effects of increased overnight supervision on resident education, decision‐making, and autonomy

“…7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient-level outcomes by both faculty and housestaff. 8 Whether increased supervision and resident autonomy can coexist remains undetermined.…”

Defining the Role of the Academic Neurohospitalist in Residency Education

“…[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.…”