Nocturnists and residents

Internal medicine residents were surveyed about overnight supervision.

Nocturnists, or hospitalists who work in-house overnight, have become a fixture of many teaching hospitals. But how does their presence affect the internal medicine residents in the hospital at the same time?

Looking for an answer, researchers posed a new question on the survey given at the end of the 2017 ACP Internal Medicine In-Training Examination: “How often do you receive adequate supervision to ensure patient safety when you are working overnight?” They also asked residents whether their programs had an attending in the hospital overnight who was responsible for their supervision on general medicine wards.

Out of 21,000 residents, about 51% reported that their supervision at night was “always” adequate to ensure patient safety, according to results published online in April as a research letter in JAMA. About 32% responded “most of the time,” 11% responded “sometimes,” 4% responded “rarely,” and 2% responded “never.” Fifty-three percent of respondents reported having nocturnists.

ACP Hospitalist spoke about the findings with coauthors Jillian S. Catalanotti, MD, MPH, FACP, an associate professor of medicine and of health policy and management and internal medicine residency program director at The George Washington University School of Medicine and Health Sciences in Washington, D.C., and Davoren Chick, MD, FACP, ACP's Senior Vice President for Medical Education.

Q: What led you to study this issue?

Dr Catalanotti
Dr. Catalanotti

A: Dr. Catalanotti: The overall thing that led us to want to study it is just the experience that we've had. Three of the authors—myself, Alec B. O’Connor, MD, MPH, FACP, and Kathlyn E. Fletcher, MD, MA, FACP—are all residency program directors. So the experience that we have had is that traditionally, overnight is a time for residents to have more autonomy, but that also has been synonymous with less supervision.

And now, as we talk more and more about patient safety and about the clinical learning environment, it really made us start to think about, “What are we doing overnight for supervision?” Some folks have nocturnists, some don't. It was unclear to us how many programs use them, how many don't, and what their real impact is on supervision. . . . Several years ago, the [Association of Program Directors in Internal Medicine] survey had asked this of program directors, and we knew they were planning to ask it again of program directors. But we thought maybe we should actually ask the residents this question, and we didn't know anyone who had asked the residents. So that was what led us to put the questions on the ACP In-Training Exam survey, which is how we met up with Dr. Chick.

Q: What were your most interesting findings?

A: Dr. Catalanotti: A useful finding was just knowing what percent of residents actually report having nocturnists . . . and what percent of residents say that their overnight supervision is adequate. I feared that the number of residents saying that overnight supervision was always adequate for patient safety would be low. When I saw that it was only 51%, that was definitely lower than I thought it was going to be. So I think that is interesting as a sort of red flag to us all. I think maybe the most interesting finding to me personally is that even among residents who have nocturnists present, actually only 61% of those residents reported always having adequate supervision [compared to 41% among those who reported not having a nocturnist].

Q: What are the take-home points for residency and hospital medicine leaders?

A: Dr. Catalanotti: I think it's really important for program directors and/or hospital leadership to really do some personal assessment of your nighttime supervision of residents. Because it sounds like whether or not we have nocturnists, we've got a lot of room for growth in terms of trying to meet that bar of always adequately supervising our residents overnight. I think the holes we'll find are different in different programs, but this, to me, is a message that we need to go looking for those holes. We should all be speaking with our housestaff and actually thinking about, “What is our overnight supervision structure? Are we providing adequate supervision? Should we have nocturnists if we do not? If we do, what exactly is the job description of the nocturnists at our institution, and what are the roles of that nocturnist?”

Dr Chick
Dr. Chick

Dr. Chick: This study doesn't answer what the best thing is to do. But it really gets at a fundamental question, which is, are we doing enough? . . . The study says having nocturnal supervision is more about the quality of that supervision, not the specific job title of the person doing it. We need to make sure our residents have a support system that whoever it is, whether it's somebody in-house or out of the hospital, is clearly available and that there is a plan to support the patient's safety with the learner involved.

Q: What are your next steps?

A: Dr. Catalanotti: A question that this certainly makes me want to ask next is to ask hospitalist division directors, “If you have a nocturnist, what is that person's role?” Because I really wonder how much variety is out there, and I think if we all shared what we did, then we could perhaps come up with some best practices as they relate to hospitals that have trainees in them.