Restructuring an inpatient resident service to improve outcomes for residents, students, and patients.

PURPOSE: This study assesses the effects of a resident teaching service restructuring on resident, student, and patient outcomes. METHOD: Interventions included eliminating a "day float" admitting team, converting one-resident:one-intern teams to one-resident:two-intern teams, reducing patient caps from 11 to 7 patients per intern, and increasing pairing between resident teams and attendings. Resident end-of-rotation evaluations and time spent in categorized activities; student end-of-clerkship evaluations, patient logs, and subject exam scores; and hospital-collected patient outcome data were compared before (2007-2008) versus after (2008-2009) the changes. RESULTS: Interns covered fewer patients per day post intervention (9.9 apiece to 6.3 apiece), whereas the total number of patients covered increased (2,501 to 2,916). Enjoyment of the rotation was higher post intervention for interns and senior residents. Residents' time in direct patient care activities and with interns increased post intervention, but residents spent less time with medical students. Students' ratings of several aspects of the clerkship were significantly higher in the postintervention year. Students evaluated more previously unevaluated patients post intervention (32.6% to 45.8%, P < .001), but subject exam scores were unchanged. The median length of stay decreased post intervention (5.0 to 4.0 days, P = .02), and fewer patients required ICU care (11.2% to 7.9%, P < .001). These differences persisted after adjusting for multiple covariates. CONCLUSIONS: An intervention that reduced handoffs and intern patient census and that increased hospitalist pairing was associated with improved resident and student experiences, a favorable impact on patient outcomes, and probable cost savings.

Association between hand-off patients and subject exam performance in medicine clerkship students.

BACKGROUND: Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students. OBJECTIVE: To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance. DESIGN: Observational study over 1 year. PARTICIPANTS: Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems. PRIMARY OUTCOME: Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores. MAIN RESULTS: Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34). CONCLUSIONS: Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.

The effect of nonteaching services on the distribution of inpatient cases for internal medicine residents.

PURPOSE: Nonteaching services (NTSs) are becoming increasingly prevalent in academic hospitals. This study was designed to determine whether the presence of an NTS is associated with higher acuity and altered case mix on the teaching service. METHOD: The authors carried out a retrospective, cross-sectional analysis of data about all general medical admissions between January 1, 2005 and June 30, 2005 to either of two teaching hospitals in Rochester, New York. A total of 6,907 inpatients were studied, of whom 1,976 (29%) were admitted to medicine resident services and 4,931 (71%) were admitted to NTSs. Hospital billing databases were used to determine patient demographics, ICD-9 diagnoses, Charlson Comorbidity Index scores, and patient disposition. RESULTS: Compared with NTS patients, patients on resident services had higher median Charlson Comorbidity Index scores (3.0 versus 2.0, P < .001) and numbers of comorbidities (9.0 versus 8.0, P < .001) and were more likely to require intensive care (15.5% versus 7.6%, P < .001) and to die in the hospital (8.2% versus 4.5%, P < .001). Patients on the resident services were more likely to have acute renal failure, respiratory failure, septicemia, and HIV. Residents were less likely to care for patients with primary diagnoses of chest pain, cellulitis, alcohol withdrawal, and sickle cell crisis. The differences in patients' conditions between resident services and NTSs were similar in the two hospitals and also among patients who had not received intensive care. CONCLUSIONS: Patients on resident services may be more medically complex and more likely to have high-acuity diagnoses than patients on NTSs. How these differences affect residents' education, residents' career decisions, and practice styles deserves further study.

Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.

There has been considerable change in the practice of internal medicine in the past quarter century, including the rise of specialization, increasing time pressure, the hospitalist movement, and the rapidly changing responsibilities of internists in inpatient and outpatient settings. Training programs have not adequately responded to these trends, and there is a consensus that the residency education system urgently needs redesign.