Resident Transition: Chances are, many of us have heard of the saying, “Don’t get sick in July,” which refers to the perceived and possibly real association between the start of a new academic year and worse patient outcomes in teaching hospitals. There’s also literature suggesting that weekend admissions are associated with increased mortality. Add to this the findings of a new study published in this month’s JAMA regarding increased risk of mortality associated with resident service changes, and one is left with no “good time” to get sick. But are these findings valid? In this retrospective study, the authors looked at 230,000+ admissions to internal medicine services at 10 US Veterans Health Administration hospitals and associations between in-hospital, 30-day and 90-day mortality and readmission rates with resident care transitions. After adjusting for important comorbidities, resident transition was associated with a statistically significant increase in risk of mortality (OR 1.21, 95% CI 1.12 – 1.31 for 30-day mortality with intern + resident transition). However, in an alternative analysis that compared patients admitted 2 days prior to resident transitions with those admitted on days not associated with service changes, there was no significant association between resident transition and mortality. This suggests that the increased risk of mortality observed in the original analysis may be due to inadequate adjustment for other important confounding variables in this observational study looking at a complex care delivery system where resident transition is just one small piece of the process. Having said that, given what we know about how important information can be missed during handoffs, this study should make us consider strategies to ensure safety of patients regardless of when they are admitted to the hospital. — Sarang Kim, MD
Chief Resident Commentary: We asked one of our internal medicine chief residents to comment on this article and to consider the idea of minimizing resident transitions, perhaps by making a service rotation longer than the typical 4 weeks:
While on service as a resident, I noticed that there arises the occasion that you kind of feel like your “wheels are spinning” with a certain patient. You and your team are stuck in a rut, and nothing really gets done for the patient. Often times in those situations, I looked forward to my attending changing out, or even the whole resident team changing out just so that the patient got a fresh perspective of their case. Sometimes that’s exactly what a patient needs to advance in their care.
The obvious downside of being on service longer than 4 weeks would be elimination of the coveted “4+1” block schedule (4 weeks inpatient + 1 week outpatient). I think one might also run into serious burnout possibilities with being on service longer than a month. It’s physically and emotionally draining to be on service for that long without a break. We also have residents doing only 2-week blocks and in some rare cases 1-week blocks, which further increase handoffs. But with the constraints of the rotating 4+1 system and giving residents the ability to choose their own vacation weeks, these shorter rotations seem inevitable from a scheduling perspective. Maybe a good solution would be to change out the senior resident and intern in a “staggered” manner, as is done in some other programs. So when the senior resident switches, the intern stays on the team and vice-versa. This way, there’s always someone who has some degree of knowledge (hopefully) about the patient.
Daniel Schaer, MD, MPH
Department of Medicine
Rutgers-Robert Wood Johnson Medical School
Denson et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA 2016;316(21)2204-2213.