Jeanne M. Farnan, MD, MHPE

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, 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.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, 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.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, 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.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.