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Background: Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning. Aim: Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection. Setting/Participants: Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017. Program Description: Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents. Program Evaluation: Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions. Discussion: Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication. [ABSTRACT FROM AUTHOR]

Background: Despite the use of 'patient ownership' as an embodiment of professionalism and increasing concerns over its loss among trainees, how its development in residents has been affected by duty hour regulations has not been well described. In this qualitative study, we aim to outline the key features of patient ownership in internal medicine, factors enabling its development, and how these have been affected by the adoption of a night float system to comply with duty hour regulations. Methods: In this qualitative descriptive study, we interviewed 18 residents and 12 faculty internists at one university centre and conducted a thematic analysis of the data focused on the concept of patient ownership. Results: We identified three key features of patient ownership: personal concern for patients, professional capacity for autonomous decision-making, and knowledge of patients' issues. Within the context of a night float system, factors that facilitate development of patient ownership include improved fitness for duty and more consistent interactions with patients/families resulting from working the same shift over consecutive days (or nights). Conversely, the increase in patient handovers, if done poorly, is a potential threat to patient ownership development. Trainees often struggle to develop ownership when autonomy is not supported with supervision and when role-modelling by faculty is lacking. Discussion: These features of patient ownership can be used to frame discussions when coaching trainees. Residency programs should be mindful of the downstream effects of shift-based scheduling. We propose strategies to optimize factors that enable trainee development of patient ownership. [ABSTRACT FROM AUTHOR]

The aims of the study are to identify factors contributing to preliminary interpretive discrepancies on overnight radiology resident shifts and apply this data in the context of known literature to draw parallels to attending overnight shift work schedules. Residents in one university-based training program provided preliminary interpretations of 18,488 overnight (11 pm–8 am) studies at a level 1 trauma center between July 1, 2013 and December 31, 2014. As part of their normal workflow and feedback, attendings scored the reports as major discrepancy, minor discrepancy, agree, and agree--good job. We retrospectively obtained the preliminary interpretation scores for each study. Total relative value units (RVUs) per shift were calculated as an indicator of overnight workload. The dataset was supplemented with information on trainee level, number of consecutive nights on night float, hour, modality, and per-shift RVU. The data were analyzed with proportional logistic regression and Fisher's exact test. There were 233 major discrepancies (1.26 %). Trainee level (senior vs. junior residents; 1.08 vs. 1.38 %; p < 0.05) and modality were significantly associated with performance. Increased workload affected more junior residents' performance, with R3 residents performing significantly worse on busier nights. Hour of the night was not significantly associated with performance, but there was a trend toward best performance at 2 am, with subsequent decreased accuracy throughout the remaining shift hours. Improved performance occurred after the first six night float shifts, presumably as residents acclimated to a night schedule. As overnight shift work schedules increase in popularity for residents and attendings, focused attention to factors impacting interpretative accuracy is warranted. [ABSTRACT FROM AUTHOR]

Objective: To study the design, method of implementation, perceived benefits, and problems associated with a night float system.Design: Self-administered questionnaire completed by program directors, which included both structured and open-ended questions. The answers reflect resident and student opinions as well as those of the program directors, since program directors regularly obtain feedback from these groups.Setting/participants: The 442 accredited internal medicine residency programs listed in the 1988-89 Directory of Graduate Medical Education Programs.Results: Of the 442 programs, 79% responded, and 30% had experience with a night float system. The most frequent methods for initiating a night float system included: decreasing elective time (42.3%), hiring more residents (26.9%), creating a non-teaching service (12.5%), and reallocating housestaff time (9.6%). Positive effects cited include decreased fatigue, improved housestaff morale, improved recruiting, and better attitude toward internal medicine training. The quality of medical care was considered the same or better by most programs using it. The most commonly cited problems were decreased continuity of care, inadequate teaching of the night float team, and miscommunication.Conclusion: Residency programs using a night float system usually observe a positive effect on housestaff morale, recruitment, and working hours and no detrimental effect on the quality of patient care. Miscommunication and inadequate learning experience for the night float team are important potential problems. This survey suggests that the night float represents one solution to reducing resident working hours. [ABSTRACT FROM AUTHOR]

Limitation of resident working hours has been a critical issue for training programs in recent years. At Providence Medical Center, residents and faculty collaborated in developing goals, implementation strategies, and an evaluation process for a new ward float system. The goals of the float system were to reduce fatigue, facilitate education, maintain continuity of care, and minimize the negative impact of training on residents' personal lives. Evaluation revealed: 1) 74% of the residents preferred Providence Medical Center float system (PMCF) to either night float (NF) (13%) or standard everyfourth-night call (EFNC) (13%); and 2) PMCF was perceived to ensure quality patient care to a greater degree than was NF, to better facilitate resident education than was NF, and to have a less negative impact on personal lives than was EFNC. [ABSTRACT FROM AUTHOR]

Objectives: To develop and test a scaled program evaluation questionnaire focusing on resident satisfaction with workload, learning environment, and stress. Design/participants: Phase 1: A cross-section of 92 residents from five programs completed questionnaires for factor analysis and descriptive statistics. Phase 2: A three-year prospective study of questionnaire responses in a single program. Questionnaire development: After extensive literature review, 33 Likert-scaled statements were written, dealing with situational, personal, and professional issues. After pilot testing, the 92 questionnaires obtained in Phase 1 were factor analyzed, resulting in three distinct scales: workload, faculty/learning environment, and stress. Interventions: Program changes in Phase 2 included the introduction of a night float between 1989 and 1990, and an increase in senior resident call between 1990 and 1991. Results: Phase 1: The first-year residents reported significantly less stress and generally greater satisfaction with workload and learning environment than did the second- or third-year residents. Marked differences between programs were also present in the mean scores on all three scales. Phase 2: The introduction of a night float did not significantly affect response to the questionnaire, but the increase in nights on call significantly increased stress and dissatisfaction with the faculty/learning environment. Conclusions: This study demonstrates the techniques needed to develop and use scaled program evaluation questionnaires. It is hoped that widespread use and validation of such instruments may result in greater responsiveness to the needs of trainees and more facilitative environments in which to acquire medical knowledge. [ABSTRACT FROM AUTHOR]

In 1989, the internal medicine residency training program at St. John's Episcopal Hospital changed from a standard one-in-four on-call system to a night float system of resident on call. Using a confidential questionnaire that assessed the opinions of medical nurses, the nurses were asked which system they preferred, and how the change to a night float system of resident on call affected medical resident performance. A significant majority of the nurses preferred night float over a standard system of resident on call. Most nurses responded that because night float allows residents to get more rest, residents make fewer mistakes and are easier to work with. Residents on night float were not considered to be more knowledgeable. The responders indicated that night float did not create confusion about which resident to call for a patient problem. [ABSTRACT FROM AUTHOR]

To examine the effect of a night float call system (NFS), a battery of neuropsychologic tests was administered to housestaff after call during an overnight call system (ONCS), and the results were compared with the results obtained during a NFS. Although NFS housestaff were less sleep-deprived, results of tests of psychomotor function were not different. Importantly, both groups had high depression, hostility, and anxiety scores. NFS housestaff had small but significantly lower depression scores, which, if not due to time of year, may represent a positive effect of the NFS. Future investigation should be directed at clarifying the aspects of residency training that adversely affect housestaff mood. [ABSTRACT FROM AUTHOR]