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OBJECTIVES Evaluate resident perception on implementation of a night float (NF) system to an otolaryngology residency program. We compared these perceptions to Accreditation Council for Graduate Medical Education (ACGME) case log data. METHODS A retrospective anonymous survey was sent to residents and alumni graduating between 2015 and 2023. Deidentified ACGME case log information was then examined for key indicator (KI) cases from post graduate year (PGY) 2 and PGY5. RESULTS Thirty (93.8%) residents and alumni responded. Residents with NF answered more positively compared to those without NF on following duty hour violations: 80-hour work week, 1-in-7 days off, 1 call every 3 days, adequate time between shifts, and allotted time after a 24-hour shift. Residents most commonly agreed that NF has improved patient care, resident education, and resident morale. Although residents with NF were neutral on PGY2 case volume effects, they disagreed that it affected overall case volume. The only KIs that differed for both PGY2 and PGY5s were airway cases (P = .004 vs P = .002) and bronchoscopy (P = .02 vs P = .006), which were significantly higher for those with NF. Thyroid surgery was the only KI higher for the residents without NF and spanned all PGY levels. CONCLUSION Residents and alumni agreed that NF implementation had a positive effect on duty hour violations. The NF system does not have significant impact on case volume. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2211-2218, 2021.

BACKGROUND: Johns Hopkins was an early adopter of an in-house nephrology fellowship night float to improve work-life balance. Our study aimed to elucidate attitudes to guide fellowship structuring. METHODS: We performed a mixed-methods study surveying Johns Hopkins fellows, alumni, and faculty and conducting one focus group of current fellows. Surveys were developed through literature review, queried on a five-point Likert scale, and analyzed with t and ANOVA tests. The focus group transcript was analyzed by two independent reviewers. RESULTS: Survey response rates were 14 (100%) fellows, 32 (91%) alumni, and 17 (94%) faculty. All groups felt quality of patient care was good to excellent with no significant differences among groups (range of means [SD], 4.1 [0.7]–4.6 [0.7]; P=0.12), although fellows had a statistically significantly more positive view than faculty on autonomy (4.6 [0.5] versus 4.1 [0.3]; P=0.006). Fellows perceived a positive effect across all domains of night float on the day team experience (range, 4.2 [0.8]–4.6 [0.6]; P

Rationale and Objectives Departmental websites are often the first exposure applicants have in researching programs. Websites provide information about resident education as well as infrastructure for resident wellness. For this study, we reviewed residency websites to evaluate resident wellness initiatives and extent of details available online. Materials and Methods Program websites for diagnostic radiology residencies listed in the 2020 ERAS program list were evaluated for 26 criteria pertaining to resident wellness. Criteria which are not radiology resident specific were also evaluated on their graduate medical education (GME) websites if unavailable on the departmental website. Results Of 189 programs, 185 (97.9%) had functioning websites for review. Book funds were mentioned by 57% (mean $3,762), and 43.5% discussed housing stipends during AIRP (mean $2,204); neither significantly correlated with program size. Retirement plan matching was present for 47.8% of programs. Almost all programs utilized night float call schedules, with relatively similar distribution of residents starting on-call duties as fall PGY2s, spring PGY2s, and starting PGY3s. Moonlighting was mentioned by 22.8% of departments. Paid wellness days were discussed in 10.8% (mean 3.1 days/year), and 37.7% described paid parental leave (mean 27.8 days/year). Less than 10% described resident mentoring, wellness committees, or non-clinical curricula. Resident retreats were mentioned by 21.6% of programs, and 11.4% described regular social activities; both were found more frequently at larger programs (chi-square analysis, p Conclusion This study evaluated radiology residency program and GME websites for information pertaining to resident wellness. While financial and clinical information was typically present for >50% of programs, information regarding social initiatives was generally lacking and may be one area to bolster resident wellness and describe on websites.

Long duty hours have been associated with significant medical errors, adverse events, and physician "burn-out". An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors' perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, plt;0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, plt;0.001) and reduce physician "burn-out" (95% vs. 5%, plt;0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician "burn-out".

Introduction As the traditional overnight call system was shown to contribute to fatigue, Singapore implemented a shift system in 2014. We aimed to compare activity levels, sleep (using a wrist actigraph), fatigue and professional quality of life between residents working on night float and those on overnight calls. Methods All Postgraduate Year 1 (PGY1) residents at our institution were invited to participate. Participants were required to wear a wrist actigraph for four months and complete two validated surveys (Epworth Sleepiness Scale [ESS] and Professional Quality of Life [ProQOL] scale) once each at the start and end of the study. Results 49 residents were recruited. Night float and on-call residents showed a comparable median (range) number of steps (10,061 [1,195-15,923] vs. 10,649 [308-21,910]; p = 0.429), amount of sleep logged (361 [149-630] minutes vs. 380 [175-484] minutes; p = 0.369) and time taken to fall asleep (6 [0-14] minutes vs. 6 [range 0-45] minutes; p = 0.726), respectively. Night float residents had less efficient sleep, with 90.5% having sleep efficiency of over 85% compared to 100% of on-call residents (p = 0.127). More night float residents reported ESS scores > 10 (73.1% vs. 38.5%) and higher burnout scores on ProQOL scale (41.4% vs. 21.4%) at the start of the study. However, this was similar to the end of the study and not statistically significant. Conclusion Physical activity and amount of sleep were not significantly different between night float and on-call residents. Residents on night float reported comparatively more fatigue and burnout.

OBJECTIVE We aimed to specifically compare the impact of a night-float system vs. a 24-hour call system on the number and types of cases performed by PGY-1 and PGY-2 general surgery residents to determine if both of these schedules could meet the ACGME first two-year 250 case minimum requirement, and if so, which schedule provided the best operative experience for PGY-1 and PGY-2 residents. DESIGN This is a retrospective review of call schedules and operative case logs of PGY-1 and PGY-2 general surgery residents. Residents were separated into two groups based on type of call schedule: 24-hour vs. night-float. The case logs of PGY-1 and PGY-2 residents were obtained from the ACGME Case Log System and data analysis was performed between the two groups. SETTING This study was performed at a general surgery residency at a hybrid academic center. PARTICIPANTS Forty-three residents met inclusion criteria. Twenty-three were part of the night-float system and 20 were part of the 24-hour call system. RESULTS Total cases and major cases for PGY-1 and PGY-2 years were compared between the two groups. The 24-hour call group had a significantly higher total number of cases than the night-float group (646.0 ± 181.5 vs. 504.8 ±148.9, p = 0.008). Major cases were also significantly higher in the 24-hour call group than the night-float group (418.5 ± 99.6 vs. 355 ± 99.5, p = 0.043). CONCLUSIONS Both the 24-hour call and night-float systems were able to meet the ACGME first two year 250 case minimum requirement as well as follow work-hour guidelines. The 24-hour call system was associated with PGY-1 and PGY-2 residents having a better operative experience than the night-float system.

Night-float rotations require general surgery interns to prioritize multiple competing patients' needs efficiently and accurately. Research is lacking on whether these skills can be taught and to what degree the prioritizations taught match overall attending surgeon expectations.A night-float situation was developed to simulate the experience of surgical interns responding to multiple patients' needs. Participants were instructed to rank order 10 patient paper-case scenarios with a variety of clinical urgencies. After completing their first ranking, the interns participated in a faculty-facilitated peer discussion (intervention) and were then instructed to re-rank their priorities. Their performance was compared pre- and post-intervention, and to the ranking of 16 surgery faculty attendings.Massachusetts General Hospital, Department of Surgery, Boston, MA.Post-graduate year (PGY) 1 surgical residents.Two classes of general surgery interns (n = 25) completed the prioritization training simulation in the middle of their internship year, one class in 2018 and one in 2020. Agreement between interns regarding patient prioritization ranking increased after the facilitated peer discussion (pre-intervention mean standard deviation = 1.8 versus 0.9 post-intervention; p = 0.03). In the post-intervention mean rank, four cases moved by one position (p0.05). The facilitated discussion resulted in increased absolute agreement between individual interns and attendings' ranks (mean agreement 38 ± 17% pre-intervention Vesus mean 50 ± 20% post-intervention, p = 0.02). The scenarios with highest agreement between interns and attendings concerned patients with the most urgent conditions. Scenarios with the lowest agreement were those ranked with medium-to-low urgency.A faculty-led facilitated discussion appears to increase clinical prioritization consistency among surgical interns and better align their prioritizations with expectations of local attending surgeons.

Background The study aims to evaluate the perceptions of pediatric residents under the night float (NF) on-call system and its impact on well-being, education, and patient safety compared with the traditional 24-h on-call system. Methods The study is prospective in nature and conducted on two pediatric resident training centers who apply the NF on-call system as a pilot project. Senior residents (PGY-3 and PGY-4) enrolled in the two training centers were invited to participate before and 6 months after the implementation of the change in the on-call system. A self-administered online questionnaire was distributed. Responses were rated using a five-point Likert-type scale (1 = strongly disagree; 5 = strongly agree). The items covered three main domains, namely, residents’ well-being, ability to deliver healthcare, and medical education experience. Pre- and post-intervention scores were presented as means and compared by t-test for paired samples. Results A total of 42 residents participated in the survey (female = 24; 57.1%). All participants were senior residents; 25 (59.6%) were third-year residents (PGY-3), whereas 17 (40.4%) were fourth-year residents (PGY-4). The participants reported that many aspects of the three domains were improved with the introduction of the NF system. The system was perceived to exert less adverse health effect on the residents (mean: 2.37 ± 1.01) compared with the 24-h on-call system (mean: 4.19 ± 0.60; P < 0.001). In addition, the NF system was perceived to lead to less exposure to personal harm and result in less negative impact on quality of care, better work efficiency, reduced potential for medical errors, more successful teaching, and less disruptions to other rotations compared with the 24 h on-call system (P < 0.001). Conclusion The perception of senior residents toward the 24-h on-call system pertains to negative impacts on well-being, education, and patient safety compared with on-call systems with restrictive duty hours, such as the NF system, which is perceived to be less harmful, to exert positive impacts on the quality of delivered healthcare services, and more useful from pedagogic aspect.

Objectives In 2018, the ACGME (Accreditation Council for Graduate Medical Education) made a change to the maximum permissible number of consecutive nights a resident trainee can be on “night float,” from six to seven nights. To our knowledge, although investigators have studied overall discrepancy rates and discrepancy rates as a function of shift length or perceived workload of a particular shift, no study has been performed to evaluate resident-faculty discrepancy rates as a quality/performance proxy, to see whether resident performance declines as a function of the number of consecutive nights. Our hypothesis is that we would observe a progressive increase in significant overnight resident – attending discrepancies over the 7 days’ time. Methods A total of 8,488 reports were extracted between 4/26/2019 to 8/22/2019 retrospectively. Data was obtained from the voice dictation system report server. Exported query was saved as a .csv file format and analyzed using Python packages. A “discrepancy checker” was created to search all finalized reports for the departmental standard heading of “Final Attending Report,” used to specify any significant changes from the preliminary interpretation. Results Model estimates varied on different days however there were no trends or patterns to indicate a deterioration in resident performance throughout the week. There were comparable probabilities throughout the week, with 2.17% on Monday, 2.35% on Thursday and 2.05% on Friday. Conclusions Our results reveal no convincing trend in terms of overnight report discrepancies between the preliminary report generated by the night float resident and the final report issued by a faculty the following morning. These results are in support of the ACGME’s recent change in the permissible number of consecutive nights on night float. We did not prove our hypothesis that resident performance on-call in the domain of report accuracy would diminish over seven consecutive nights while on the night float rotation. Our results found that performance remained fairly uniform over the course of the week.

Objectives A large discrepancy exists in resident educational activities between daytime and nighttime medical rotations. The Accreditation Council for Graduate Medical Education duty-hour regulations led to the increased adoption of the dedicated nighttime rotation called night float. Nighttime education has largely been negatively perceived by night float medical residents. Although there have been attempts to improve nighttime education, none of the initiatives included faculty-guided structured night curriculum. Our objective was to improve resident experience with and perception of nighttime education by implementing a structured, faculty-guided, nighttime educational curriculum. Methods This was an assessment of an educational initiative at a single academic medical center, Virginia Commonwealth University Health System. The internal medicine residency program implemented a teaching nocturnist program in 2013 and a novel faculty-guided nighttime teaching curriculum in 2016 called midnight report. We then evaluated resident experience with and perception of nighttime education at our institution using anonymous free-response surveys for the academic year July 2016-June 2017. Results Of the 142 eligible residents, 95 (67%) responded to the survey. The majority of the residents (54%-77%) positively perceived their experience of the nighttime educational environment during their night float rotation after implementation of the teaching nocturnist program and midnight report. Conclusions Compared with the published literature reporting negative perceptions of the nighttime educational environment by residents at different academic centers, our results showed that the majority of our residents positively perceived the impact of our new faculty-guided nighttime educational curriculum.

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. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05913-z) contains supplementary material, which is available to authorized users.

Among surgical educators, duty-hour restrictions led to concern regarding the adequacy of operative experience during residency, especially for junior residents. The American Board of Surgery recently instituted guidelines mandating "a minimum of 250 operations by the end of the PGY-2 year". A series of programmatic and institutional changes were implemented at our institution to augment the junior resident operative experience and to exceed compliance with this mandate.Operative data from Accreditation Council for Graduate Medical Education case logs for categorical and nondesignated preliminary interns from our large academic surgical residency were identified for 5 consecutive academic years, 2011 until 2016. American Board of Surgery In-Training Examination (ABSITE) scores were collected anonymously. The program systematically instituted the following changes: night float minimization, identification of new surgical opportunities, augmenting use of midlevel care providers, identification of rotations with suboptimal operative experiences, maximizing rotations with involvement of junior residents in the operating room, and systematic review of junior case logs.After implementation, average total cases for residents completing postgraduate year (PGY)-2 increased from 176 to 330 (p0.001). Specifically, there was an 18% increase for interns (p = 0.059) and a 118% increase for PGY-2 residents (p0.001). There were statistically significant increases in skin and soft tissue cases, vascular cases, endoscopy, and complex laparoscopic cases. Average case volumes for senior residents did not change. Night float time was significantly decreased (5.7 vs 3.4 wk; p = 0.04). ABSITE scores were not significantly changed during this time.Before implementation of these interventions, our program would have had 0% compliance with the 250 junior resident case rule. Within 12 months of implementation, total case volumes for residents completing PGY-2 increased by 88%-exceeding minimum standards. Overall, 100% programmatic compliance was achieved. Our program's experience exemplifies how mandates from the American Board of Surgery can lead to programmatic changes that improve the experience of surgical house officers.

Objective To evaluate the comprehensiveness of plastic surgery program websites. Design American Medical Association interactive database was accessed for the list of integrated plastic surgery programs, in June 2015. Since then, 67 plastic surgery program websites were accessed and searched for the presence or absence of 31 criteria, which were further grouped into 5 categories: First, program contact information; second, training and research; third, program setup; fourth, benefits and facilities; and fifth, information for applicants. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA test was used for comparison. Results Only 25% (17) program website had information available on more than two-thirds (21 or more of 31) of the criteria. The 3 least factors commonly available by program websites were: operative log (10%), contract (10%), and information on night float (25%). The 3 most commonly available factors included: coordinator information (92%), number of residents (92%), and comprehensive faculty list (88%). Less than 50% of the programs provided information regarding fellowship opportunities, active and previous research projects, and operative logs. There was no difference in amount of information on program websites when analyzed for program size or program geographic location. Conclusion Programs should consider revising their websites to include aforementioned 31 criteria. This would make applicants and potential resident physicians better informed of the programs before the interview process such that they would be more likely to apply to only those programs that match their specific aspirations.

Clear and effective communication supports interdisciplinary teamwork and prevents adverse patient events. At our academic teaching hospital, poor communication between surgical residents and nurses was identified as a recurring problem, particularly on the inpatient general surgery night float rotation.A standardized nightly huddle with surgical residents and nurses was developed and implemented as a resident-led quality improvement initiative on two acute care units. The huddle was evaluated with pre/post surveys of nurses and residents, as well as analysis of paging volume and rapid response events.Nightly huddles significantly improved nurses' perception of interdisciplinary teamwork and communication (p 0.00005). With nightly huddles, significantly more nurses were able to identify and name the on-duty night float resident at the end of a 4-week rotation (p 0.00005). Nurses perceived a positive impact on patient care and work environment. There were no changes in the number of nighttime pages or rapid responses.With night float rotations becoming a standard part of residency training, standardized huddles can enhance nighttime collaboration between residents and nurses.

BACKGROUND: In the present milieu of rapid innovation in undergraduate medical education at US medical schools, the current structure and composition of clinical education in Internal Medicine (IM) is not clear. OBJECTIVE: To describe the current composition of undergraduate clinical education structure in IM. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: IM core clerkship and post-core clerkship structure descriptions, including duration, educational models, inpatient experiences, ambulatory experiences, and requirements. KEY RESULTS: The survey response rate was 83% (107/129). The majority of schools utilized one core IM clerkship model (67%) and continued to use a traditional block model for a majority of their students (84%). Overall 26% employed a Longitudinal Integrated Clerkship model and 14% employed a shared block model for some students. The mean inpatient duration was 7.0 ± 1.7 weeks (range 3–11 weeks) and 94% of clerkships stipulated that students spend some inpatient time on general medicine. IM-specific ambulatory experiences were not required for students in 65% of IM core clerkship models. Overall 75% of schools did not require an advanced IM clinical experience after the core clerkship; however, 66% of schools reported a high percentage of students (> 40%) electing to take an IM sub-internship. About half of schools (48%) did not require overnight call or night float during the clinical IM sub-internship. CONCLUSIONS: Although there are diverse core IM clerkship models, the majority of IM core clerkships are still traditional block models. The mean inpatient duration is 7 weeks and 65% of IM core clerkship models did not require IM-specific ambulatory education. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04892-0) contains supplementary material, which is available to authorized users.

Radiology residency training has undergone substantial changes, including increased utilization of night float systems, late and/or overnight attending radiology in-house coverage (LOAR), and restructuring of the radiology boards. The purpose of this study is to evaluate radiology residents' perceptions regarding these changes and their impact on resident training using an anonymous, web-based survey that was distributed to radiology residents across the United States. A total of 345 current radiology residents completed the survey. A substantial number of radiology residents perceive that LOARs have negative impact on their development of independence and efficiency during the on call period. Residents are concerned about the timing of the core exam and match fellowship interviews, the timing of the certifying exam, and that graduating as board-eligible radiologists will harm their job search.

Phenomenon: The call component of clerkship presents students with unique opportunities and challenges. Clerkship programs employ various call modalities, including traditional call, night float, and evening call. The impact of these call models on the student experience has not been explored in depth. Approach: Focus groups were conducted with 4th-year medical students, exploring their multidimensional experiences with various call modalities during clerkship. Transcripts were analyzed using thematic analysis. Findings: Thirty-nine students participated in 6 focus groups. Four overarching themes were identified: (a) educational value conferred by clinical exposure and teaching, (b) maintaining quality of life and developing features of burnout, (c) formation of professional identity via relationships with team members, and (d) perceived quality of patient care provided. Students associated evening call with burnout and poor educational value but also better patient continuity of care. Night float and traditional call contributed to a sense of team bonding and had enhanced perceived educational value while on call but resulted in loss of formal academic teaching time. Insights: Call modality impacts student learning, well-being, professional identity formation, and patient care; however, trade-off among these elements exists across all call models. Enhancing the value of student call experience may be achieved by implementation of various purposeful changes. These may include creating consistency between student and resident call schedules, maximizing recovery time between call shifts, and avoiding scheduling of students for call prior to academic sessions.

Background Some residency programs responded to duty hour restrictions by implementing night rotations. Night supervision models can vary, resulting in potential patient safety issues and educational voids for residents. Objective We evaluated the impact of multiple evidence-based interventions on resident satisfaction with supervision, perception of the education value of night rotations, and residents' use of online educational materials. Methods The night team was augmented with an intern to assist with admissions and a senior resident (the “nighthawk”) to supervise inpatient care and deliver a night medicine curriculum. We instituted a “must-call” list, with specific clinical events requiring mandatory attending notification, and reduced conflict in the role of the night float team. We studied patient contact, online curriculum use, residents' perceptions of nighthawk involvement, exposure to educational materials, and satisfaction with supervision. Results During the first half of academic year 2016–2017, 51% (64 of 126) of trainees were on the night medicine rotation. The nighthawk reviewed 1007 intern plans (15 per night; range, 6–36) and supervised 215 hands-on evaluations, including codes and rapid responses (3 per night; range, 0–12). The number of users of the online education materials increased by 85% (13 to 24), and instances of use increased 35% (85 to 115). The majority of residents (79%, 27 of 34) favored the new system. Conclusions A nighthawk rotation, a must-call list, and reducing conflict in night team members' roles improved resident satisfaction with supervision and the night medicine rotation, resulting in increased communication.

Purpose In July 2012, in response to residents' concerns regarding the impact of the traditional 24-hour call system on their personal well-being and educational experience, the University of British Columbia Radiology residency program adopted a 12-hour night float system. This shift takes place in the context of increasing concerns, both across Canada and internationally, about resident well-being and the impact of prolonged duty hours on patient care. Methods An anonymous survey was distributed to all 25 postgraduate years 2-5 University of British Columbia radiology residents 12 months after the introduction of night float. This study sought to solicit residents' feedback about these changes and to identify potential future changes to optimize the call system. Results The response rate was 100%; 96% of residents were in favor of continuing with night float rather than the traditional call system; 72% of residents reported that their judgement was affected secondary to being on night float. Although most residents described varying degrees of impairment, the rate of acute discrepancies between resident preliminary and attending radiologist final reports decreased by more than half, from 2% to less than 1%. Conclusions The vast majority of our residents were in favor of maintaining the night float call system. Night float had a beneficial effect on the resident educational experience: by eliminating the pre-call morning and post-call day off rotation, residents gained an additional 24 days per year on other clinical rotations.

Luke C Kohan,1,* Vijaiganesh Nagarajan,1,* Michael A Millard,2 Michael J Loguidice,2 Nancy M Fauber,1 Ellen C Keeley1 1Division of Cardiology, 2Department of Medicine, University of Virginia, Charlottesville, VA, USA * These authors contributed equally to this work Objectives: To assess if a change in our cardiology fellowship program impacted our ST elevation myocardial infarction (STEMI) program. Background: Fellows covering the cardiac care unit were spending excessive hours in the hospital while on call, resulting in increased duty hours violations. A night float fellow system was started on July 1, 2012, allowing the cardiac care unit fellow to sign out to a night float fellow at 5:30 pm. The night float fellow remained in-house until the morning. Methods: We performed a retrospective study assessing symptom onset to arrival, arterial access to first device, and door-to-balloon (D2B) times, in consecutive STEMI patients presenting to our emergency department before and after initiation of the night float fellow system. Results: From 2009 to 2013, 208 STEMI patients presented to our emergency department and underwent primary percutaneous coronary intervention. There was no difference in symptom onset to arrival (150±102 minutes vs 154±122 minutes, p=0.758), arterial access to first device (12±8 minutes vs 11±7 minutes, p=0.230), or D2B times (50±32 minutes vs 52±34 minutes, p=0.681) during regular working hours. However, there was a significant decrease in D2B times seen during off-hours (72±33 minutes vs 49±15 minutes, p=0.007). There was no difference in in-hospital mortality (11% vs 8%, p=0.484) or need for intra-aortic balloon pump placement (7% vs 8%, p=0.793). Conclusion: In academic medical centers, in-house cardiology fellow coverage during off-hours may expedite care of STEMI patients. Keywords: door-to-balloon time, 24/7 in-house call, cardiology fellow

Objective To qualify and characterize resident overnight activity. Design A prospective 3-phase study was conducted of surgical residents with attention to activities performed on the overnight rotation: needs assessment, direct observation of activities, and feedback. Setting This study was conducted at the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. This is both a tertiary referral center and the only American College of Surgeons (ACS) verified level 1 trauma center in the state. Participants This study included current surgical residents within the residency program. Results During the study period, 270 pages were individually recorded, with 60% of these pages defined as time-sensitive activities. In addition, most of the pages involved pressing patient-care issues irrespective of postgraduate year level. Analyses revealed that residents spend most of their time performing educational activities (62%). On feedback, residents reported overall satisfaction with the learning opportunities during night-shift (6.4/7.0) and indicated their perceptions of an adequate balance of service and education on night float (6.6/7.0). This correlates with our annual rotation assessment where residents identify night-float as an overall positive experience which provides educational benefit. Conclusions Work-hour restrictions induce residency programs to adapt to new training models. Our results report a breakdown of resident activities while on night-float and demonstrate that overnight shifts continue to provide important educational opportunities during training.

BackgroundResident work hour restrictions have led to the creation of the ‘night float’ to care for the patients of multiple primary teams after hours. These residents are often inundated with acute issues in the numerous patients they cover and are less able to address non-urgent issues that arise at night. Further, non-urgent pages may contribute to physician alarm fatigue and negatively impact patient outcomes.ObjectiveTo delineate the burden of non-urgent paging at night and propose solutions.MethodsWe performed a resident review and categorisation of 1820 pages to night floats between September 2014 and December 2014. Both attending and nursing review of 10% of pages was done and compared.ResultsOf reviewed pages, 62.1% were urgent and 27.7% were non-urgent. Attending review of random page samples correlated well with resident review. Common reasons for non-urgent pages were non-urgent patient status updates, low-priority order requests and non-critical lab values.ConclusionsA significant number of non-urgent pages are sent at night. These pages likely distract from acute issues that arise at night and place an unnecessary burden on night floats. Both behavioural and systemic adjustments are needed to address this issue. Possible interventions include integrating low-priority messaging into the electronic health record system and use of charge nurses to help determine urgency of issues and batch non-urgent pages.

Objective To determine the attitudes of residents, attending obstetricians, and nursing staff members towards night float resident call, compared with a traditional 24-hour call system. Methods In June 2012, obstetrics and gynaecology residents at the University of Toronto who had participated in both a night float and a 24-hour call system were asked to complete an electronic survey. Attending obstetricians and nurses in the labour and delivery unit at two tertiary care hospitals with a night float system of resident call completed electronic and paper surveys, respectively. Questions asked respondents to compare the two systems of call with respect to resident morale, fatigue, and continuity of care, and to indicate which system of call they preferred. Results Surveys were completed by 20/24 residents (83%), 24/39 attending obstetricians (62%) and 47/58 nurses (81%). Most residents reported less fatigue (17/20, 85%) and improved continuity of care (15/20, 75%) while doing night float call, but morale was mixed. Overall, 14/20 (70%) residents preferred the night float system. Staff perceptions of resident night float call were mixed in all areas, and most reported no difference in resident morale (17/24, 71%). Nurses found residents were less fatigued (32/47, 68%) and easier to work with (34/47, 72%), and felt that night float call improved continuity of care (37/47, 79%). Conclusion Resident attitudes towards night float call are mostly positive. Attitudes of attending obstetricians are mixed, but nurses prefer this system of resident call.

Because of work hour regulations, many surgical residency programs have moved to a night float system. Previously, our medical students took call for 24 hours, whereas currently they also follow a night float system. This study looked at their evaluations of these 2 systems.Students were anonymously surveyed to evaluate the rotation (on a 5-point scale) as well as various components including night call. Responses from each group were compared.There were 104 students included: 46 in the traditional 24-hour call group and 58 in the night float group. Students rated night call significantly higher in the night float system (4.62 ± .64 vs 3.52 ± 1.00, P.001). There was no difference in the other components or the overall evaluation.After switching to a night float system, students had a much more positive perception of their night call experience. We believe more clerkships should switch to a night float system.

We aimed to measure the effects of a residency program's mid-year shift from 24-h call to night float on resident burnout and quality of life. At the end of the year, residents who started the year with 24-h call had worse burnout and quality of life, with statistical significance and large effect sizes. Exposure to a twenty-four hour call system, when compared to a full year of night float, may be associated with increased burnout and decreased quality of life, though measuring this effect is not straightforward.

OBJECTIVE Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital. METHODS The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders. RESULTS A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35). CONCLUSIONS This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

Background Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience and patient care. Objective To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program. Methods In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (front-fill). Results Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (P < .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (P < .001). Reports of adequate time with patients increased from 16 to 36 (P < .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (P < .001). Reports of leaving on time after call days rose from 12 to 33 (P < .01), and overall satisfaction increased from 26 to 35 (P = .002). Results were similar when residents were resurveyed 6 months after the intervention. Conclusions Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.

Background The current level of continuity of care for following up a single patient through preoperative evaluation, surgery, and postoperative care is unknown. Methods A survey of residents was performed, asking for their best guess regarding the number of patients seen for 6 common and 4 uncommon surgeries, and ranking barriers to continuity of care. The length of time to achieve single-patient continuity of care in 5 patients was derived as well as the creation of odds ratios for the barriers. Results A total of 274 residents (56 programs) completed surveys. Residency length was 7 years for common surgeries and 9 for complex surgeries. The 30-hour work restrictions, inability to attend clinic, and floor/ward duties were the barriers to continuity of care. These data were unaffected by type of program, the presence of a night float system, or residency year. Conclusions Achieving the level of continuity of care used in this article will require a radical change in the length or structure of general surgery residency programs.

Background We hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion. Methods A 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed. Results We surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year. Conclusions A week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

Background Resident night-float systems have been associated with adverse outcomes. We hypothesized that an obstetric anesthesia night float would increase the incidence of unintentional dural punctures. Methods The July to December incidence of unintentional dural puncture before (control group) and with night float (night-float group) was compared retrospectively. The incidence of unintentional dural puncture by day of week and trainee level was evaluated. Results The unintentional dural puncture rate of control group was 0.73% (20 of 2758) vs 1.49% (39 of 2612) in the night-float group (P = 0.008; relative risk = 2.06; 95% confidence interval = 1.23-3.74). The proportion of unintentional dural punctures attributed to clinical anesthesia-1 residents in the night-float and control groups was 28.2% (11 of 39) and 5.0% (1 of 20), respectively (relative risk = 5.64; 95% confidence interval = 1.07-152; P = 0.044). Conclusions Implementation of night float increased the incidence of unintentional dural puncture.

Objective The purpose of this study was to evaluate the effects of 2 different call schedules on post-call cognitive function and satisfaction. Study design This is a prospective observational pilot study of 20 third-year medical students. A computerized cognitive function test was administered to students with call every fourth night or a week of 12-hour "night float" shifts. Questionnaires were completed to assess satisfaction on different call schedules. Results There was no significant difference in cognitive functioning scores for students on either call schedule. Responses on questionnaires indicate that night float allows students to feel more alert for clinical duties ( P = .03). Conclusion There is no significant impact of sleep deprivation on cognitive scores; however, night float allows students to feel subjectively more alert for clinical duties.

Objectives: We surveyed the nation's internal medicine residency training program directors to determine the range and frequency of existing methods by which float experiences are evaluated. Methods: We sent questionnaires to the program directors of all 396 internal medicine residency training program sites in the country. Information requested included program characteristics, months devoted to float experiences in each year of training, and the location and purpose of the rotation. Program directors were also asked to choose among descriptors characterizing the evaluative process. Results: There were 139 responding programs (39%), 134 with data that could be aggregated. Responding programs were similar to all programs nationally in the distributions of size and university sponsorship. Overall, 76% of programs employed a night float for any period of time, and 71% currently had one, on average for 6.7 years. Mean months of float experience during residency was 2.4 months, significantly longer in programs that were not university based. Float experiences were evaluated in 89% of those programs who employed them, with ten different methods reported. University-based programs were significantly less likely to use chart review as a method of evaluation, but no other differences in methodology were significant. Conclusions: Float rotations are common among internal medicine residency training programs. Evaluative methods vary, but one or more are applied in the vast majority of programs.

BACKGROUND: Residency training programs use the night float system increasingly to meet the new resident work hour regulations. OBJECTIVE: To assess and compare residents’, attendings’, and nurses’ perceptions of the night float system. DESIGN: A survey study. PARTICIPANTS: One hundred and seven residents, 48 attendings, and 69 nurses in a university-based multicenter internal medicine residency program. MEASUREMENTS: Perceived impact on patient care, resident training, and resident performance. RESULTS: The overall response rate was 75%. In general, more residents than both attendings and nurses had positive opinions regarding the night float system, particularly in relation to patient care. Only a small proportion of residents and attendings thought positively about the night float’s impact on training quality (29.9%; 18.2%), daily feedback (23.0%; 9.1%), and end of rotation evaluation (21.8%; 6.1%). Less than half of the nurses had positive perceptions of the night residents’ performance in terms of promptness (40.9%), physical availability (38.6%), familiarity with the patients’ cases, and management plans (15.9%), communication of management plans to nurses (36.4%), professional respect and trust (43.2%), and teamwork (45.5%). CONCLUSIONS: Residents had more positive perceptions than attendings and nurses. Nurses, in particular, had negative perceptions of resident performance in the setting of the night float system.

Purpose There has been much concern regarding the impact of work-hour reforms on the operative case volume of surgical residents. Operative case volume by PGY year and clinical rotation were examined to determine if changes in work hours affected residents' operative case volume. Methods A careful but aggressive plan of work-hour reduction was devised for the residency of the authors' institution with the goal to decrease work hours while maintaining optimal patient care and resident education, including operative case volume. Changes made included hiring physician extenders (PEs), decreasing call schedules to every fourth night (with the next day free from clinical activities—Q4) or call from home (HC), and night float rotation coverage for services (NF). Case volume before (academic year 2002) and after (academic year 2003) changes were compared by PGY year, for all residents and for specific rotations—private general surgery, which had changes of PE, HC, and NF for PGY5; PE, Q4 and NF for PGY1 and 10% exemption for work hours; Churchill service (a resident-run ward teaching service), which had changes of PE and Q4 for PGY5 and PGY1 and 10% exemption for work hours; and vascular surgery, which had HC and NF for PGY5. Total case volume on these services was likewise compared. Statistical analysis was by student t test. Operative case volume was measured with data from the resident-entered information on the ACGME Surgical Operative Log (SOL). Case volume for PGY4 residents could not be compared over this time period because of lack of access to archived data by PGY year for graduated residents through the ACGME SOL. Work hours before and after rotation changes were measured with an intranet-based monitoring system. This article is a retrospective review of the affects of these work-hour changes on operative case volume. Results Total case volume for the general surgical services (both private and Churchill) was unchanged over this period (5905 in 02, 5930 in 03), and likewise for the vascular service (1101 vs 1196). Overall, there was no change in mean operative volume per year for surgical residents in this program (231 cases in 2002, 246 cases in 2003; p=0.61). For PGY5 residents, the case volume increased; 339 cases 02, 390 in 03, and p=0.05. Mean case volume for PGY5 residents increased on the private general surgery service (136 in 02, 160 in 03, p=0.03), but it remained stable on the Churchill service (137 in 02, 158 in 03, p=0.39) and vascular service (65 in 02, 73 in 03, p=0.42). For PGY3 residents, case volume remained stable (171 in 02, 187 in 03, p=0.62), as it did for PGY2 and PGY1 residents (PGY2: 148 in 02, 121 in 03, p=0.12; PGY1: 265 in 02, 246 in 03, p=0.23). However, operative case volume for PGY1 residents did decrease on the private general surgery service (mean 52 cases per month 02, 43 cases per month 03, p=0.07), while remaining stable on the Churchill service (mean 23 cases per month 02, 25 cases per month 03, p=0.66). Average hours worked per week decreased significantly over the time period. Before work-hour reforms, residents' average work hours were as follows: PGY1 105, PGY2 97, PGY3 78.7, PGY4 111, and PGY5 92. After the changes, average work hours were PGY1 81.5, PGY2 77.7, PGY3 78.7, PGY4 75.5, and PGY5 75.9. Conclusions Work-hour limitation can be devised to maximize resident education, optimize patient care, and maintain resident operative volume. Although some changes (HC, PE, NF) seemed to increase the operative case volume for PGY5 residents, others had no effect (Q4, HC). There does not seem to be a clear relationship between types of changes and case volume. At the PGY1 level, Q4 and PE changes decreased operative experience on 1 rotation but not on another, although the difference in this decrease seems clinically insignificant. Individualization of changes to meet the needs of specific rotations seems more important than specific changes in coverage pattern. Perhaps the most important finding is that changes can be made to bring work hours into compliance without materially effecting operative case volume.

Background The effect of resident work-hour restriction on patient outcome remains controversial. Methods Demographic data, mechanism of injury, length of hospital stay length of intensive care unit (ICU) stay, ventilator days, mortality, and complication data were prospectively collected for 11 months before and 11 months after institution of a rotating night-float system. Seven attending surgeons reviewed all complications and categorized each as preventable, potentially preventable, or nonpreventable. Results Both study periods were comparable with respect to demographic data, mean Injury Severity Score, mechanism of injury, and admissions. Limitation of resident work hours had no effect on length of hospital or ICU stay, ventilator days, or mortality. Work-hour restrictions did not increase or decrease the total number of complications nor did it alter the distribution of those determined to be preventable or potentially preventable. Conclusions Resident work-hour restrictions were not associated with significant improvement or deterioration in patient outcome.

Background The ACGME mandated a change in resident work hours effective July 2003. We postulated that taking a block of night call would provide an opportunity for residents to improve clinical decision-making without detracting from operative experience. Methods The educational benefit of the Night Float model was evaluated weekly by anonymous questionnaires that assessed resident conference attendance, operative experience, attending teaching interactions, and consultations for the previous seven days. Results Preliminary results demonstrated that a higher percentage of Night Float residents reported less exposure to each educational opportunity than their colleagues. These data prompted several remedial interventions that resulted in significant improvement. Compliance with the 80-hour workweek was equal for both groups. Conclusions The Night Float model has the advantage of fulfilling ACGME requirements, but it also has the potential to limit educational experience. Continued monitoring and faculty intervention are critical if we are to succeed in our goal to provide our residents with the best possible training.

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents’ fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

In the late 1980s physician residency training programs developed the night float rotation, characterized by a sequence of 5 - 15 days of night work without any daytime duties, thereby involving an abrupt reversal of the wake - sleep schedule. We examined the effect of the night float rotation on sleep, mood and performance of pediatric residents. Residents completed sleep diaries daily, and tests of mood (Profile of Mood States) and attention (Conner's Continuous Performance Test) three times a week during the two-week night float rotation, and during equivalent blocks of time of their daytime rotations. Results show that, despite having ample opportunity to sleep during the day, while on night float rotation residents slept less than during the nights of their normal daytime rotations, 6.3 h +/- 2.5 h and 7.2 h +/- 1.7 h, respectively, p0.0001. Also, during night float compared to daytime rotations residents had increased fatigue-inertia scores, 8.7 +/- 4.1 and 4.8 +/- 2.4, respectively, p0.0001, and decreased vigor-activity scores 10.7 +/- 5.4 and 14.8 +/- 5.3, respectively, p = 0.02. The scores for attention were not significantly different between night float and daytime rotations. The correlation coefficients of fatigue with measures of attention were not statistically significant for daytime rotations. However, for night float fatigue correlated with omission errors, r = 0.51, p = 0.001 and with attentiveness r = - 0.36, p = 0.03. Training programs that adopt the night float rotation must be aware of potential deleterious effects of the night float rotation as they may lead to serious consequences on residents' performance and patients' safety.

BACKGROUND: Legal mandates to reduce resident work hours have prompted changes in the structure of surgical training programs. Such changes have included modification of on-call schedules and the adoption of "night float" resident coverage. Little is known about the effects of these changes on surgical resident education and perceptions of quality of patient care. STUDY DESIGN: The surgical housestaff and faculty at a single institution completed a 21-point Likert survey. Subjects were asked to compare parameters of resident education, patient care, and resident quality of life before and after institution of a strict 80-hour work week resident training schedule. The number of hours worked per week before and after these changes were reported. American Board of Surgery In-Training Examination (ABSITE) scores were compared for the 2 years before and after implementation of this schedule. Total number of surgical cases performed by graduating chief residents were recorded and compared for the 3 years before and after the schedule changes. RESULTS: Resident work hours reduced significantly after schedule changes were implemented. A majority of surgical residents reported an improvement in quality of life, but residents and faculty perceived changes to have a negative impact on continuity of patient care. Mean ABSITE composite percentile scores significantly improved after the reduction of working hours. ABSITE scores for junior residents improved significantly; no significant differences were noted in scores for senior residents. CONCLUSIONS: Reduction in resident work hours has salutary effects on perception of quality of life and basic education for surgical residents. These benefits may come at the expense of patient care, particularly continuity of care. This study did not directly assess patient outcomes but the perceptions of caregivers suggest that patient care may be compromised. Further research is needed to assess the longterm effects of changes on both residents and patients.

Throughout America, teaching hospitals are struggling to meet the Accreditation Council for Graduate Medical Education’s (ACGME) new resident duty-hour standards. Effective July 2011, the Common Program Requirements state that duty hours must be limited to 80 hours per week, averaged over a four-week period, including in-house call and moonlighting (although exceptions may be granted up to 88 hours “based on a sound educational rationale”). Residents must be scheduled for at least one duty-free day (without at-home call) every week, averaged over four weeks. Duty periods of interns must not exceed 16 hours. Upper level residents may be scheduled up to 24 hours of continuous duty, with up to four additional hours for transitions in care, but “strategic napping… is strongly suggested.” PGY-1 and intermediate-level residents must have eight duty-free hours between scheduled duty periods, and 14 duty-free hours after 24 hours of in-house duty. Residents must not be scheduled for more than six consecutive nights of night float, and higher level residents must be scheduled for in-house call no more frequently than every third night (averaged over four weeks). Finally, the ACGME mandated changes to the training environment to improve residents’ educational experience and to mitigate potential adverse effects of the duty-hour restrictions.1

especially important in the on-call setting. A needs assessment was performed to determine the baseline state of communication between radiology and referring services on call. Neurology was identified as an excellent example of a high-acuity service because rapid communication with radiology is needed in the managementofpatients with stroke. NEEDS ASSESSMENT All radiology and neurology residents on call over a 4-week interval were invited to participate in voluntary, anonymous needs assessment surveys. With night float systems in place in both departments, 4 radiology residents and 4 neurology residents were eligible, and all completed surveys. Findings were as follows: � Radiology reported using the

Introduction Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience. Methods PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible. Results In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3. Conclusions NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.

Medical education and the clinical world within which it is practiced have undergone unprecedented change in the last 10 years. Duty hour reform and the shift toward outcomes-based education and assessment have had a marked impact on our educational systems. 1 At the same time, many of our hospitals and clinics have undergone significant systems changes. Electronic medical records have swept the nation and, along with them, increases in physician tasks and non-face-to-face communication with patients and interprofessional colleagues. Documentation and clinical productivity pressures have increased, clinic visits have been shortened, and the pressure to reduce hospital length of stay has increased. Meanwhile, patients are seemingly getting older and sicker. These changes to the medical education and clinical world have left internal medicine physicians, whether based in the hospital or the clinic, debating and lamenting their impact. Concerns have included apprehension about the effect of these changes on the quality of patient care, patient safety, and resident education. These often heated discussions have occurred within the walls of our institutions and in public forums, including JGIM. While the debate continued, program directors in internal medicine were forced to move quickly. Perhaps the most common change was the transition from overnight call to shift-based systems. Designs vary from institution to institution, but most involve daytime shifts, with swing and night float shifts for admitting and cross-cover of patients. The day team is responsible for admitting new patients that come in during the day, but also for caring for their patients and those admitted overnight by the swing and night float residents. Another growing change is the shift to X+Y schedules, wherein residents spend a fixed number of weeks on inpatient duty (generally 3–5 weeks), followed by a week or more of outpatient, largely continuity clinic care. Again, debate has raged over the clinical and educational challenges associated with these models. The impacts of these changes have been

Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as "hold-over admissions." Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions.Survey of internal medicine residents at an academic medical center.A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p 0.01). Residents reported spending significantly (p 0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p 0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients.Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.