Lauren Block, MD, MPH

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P<0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P<0.01) and their role (42% vs 30%, P<0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P<0.01) and describe their role to patients (44% vs 29%, P<0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P<0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P<0.01; 80% vs 37%, P<0.01; and 58% vs 9%, P<0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P<0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P<0.01) and their role (42% vs 30%, P<0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P<0.01) and describe their role to patients (44% vs 29%, P<0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P<0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P<0.01; 80% vs 37%, P<0.01; and 58% vs 9%, P<0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P<0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P<0.01) and their role (42% vs 30%, P<0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P<0.01) and describe their role to patients (44% vs 29%, P<0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P<0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P<0.01; 80% vs 37%, P<0.01; and 58% vs 9%, P<0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]