Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents

Background: Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers.

Objective: To explore residents' perception of barriers to accessing overnight supervision.

Design: Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017.

Participants: All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed.

Main measures: For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention.

Key results: Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers.

Conclusions: Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.