Regulations that restrict resident work hours and call for increased resident supervision have increased attending physician presence in the hospital during the nighttime. The resulting increased interactions between attendings and trainees provide an important opportunity and obligation to enhance the quality of learning that takes place in the hospital between 6 PM and 8 AM. Nighttime education should be transformed in a way that maintains clinical productivity for both attending and resident physicians, integrates high-quality teaching and curricula, and achieves a balance between patient safety and resident autonomy. Direct observation of trainees, instruction in communication, and modeling of cost-efficient medical practice may be more feasible during the night than during daytime hours. To realize the potential of this educational opportunity, training programs should develop skilled nighttime educators and establish metrics to define success.
Dr. Hanson is assistant professor, Department of Medicine, University of Texas Health Sciences Center, and South Texas Veterans Health Care System, San Antonio, Texas.
Dr. Pierce is assistant professor, Department of Medicine, University of Colorado, Denver, Colorado.
Dr. Dhaliwal is associate professor, Department of Medicine, University of California, San Francisco, and San Francisco VA Medical Center, San Francisco, California.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Correspondence should be addressed to Dr. Hanson, 7703 Floyd Curl Dr. MC 7982, San Antonio, TX 78229-3900; telephone: (210) 358-1944; e-mail: firstname.lastname@example.org.
Educational models and mandates for physician trainees are evolving rapidly. Many authors have addressed the complexities faced by training programs and clinician–educators as they adapt to resident duty hours requirements, calls for increased value in health care delivery, and efforts to enhance patient safety.1–5 We believe an important but underappreciated challenge of this evolution in clinical training is the transformation of nighttime education, which we define as any knowledge, skills, or attitudes that trainees develop while working in a clinical setting between 6 PM and 8 AM. Teaching hospitals and training programs have traditionally provided less on-site attending supervision and limited diagnostic, treatment, and consultative options for residents and fellows who work overnight shifts.6,7 Financial and regulatory mandates to provide high-value care and enhance patient experience regardless of time of day are driving teaching hospitals to explore avenues for combining highly effective teaching and clinical care during nighttime hours, which cover more than half of a 24-hour work cycle in health care.8–11
In response to the 2011 Accreditation Council for Graduate Medical Education (ACGME) requirements, which mandate decreased maximum shift length for interns and enhanced supervision for physician trainees, training programs have increased staffing at night.12 We view this shift, which increases the number of nocturnal interactions between attending physicians and trainees, as a valuable opportunity to create a dynamic learning environment at night.
Opportunities in Nighttime Education
Nighttime medicine offers a rich environment for clinician educators to address important competencies and curricular objectives. For example, handoffs between providers take place at the start, finish, and sometimes middle of nighttime shifts, providing opportunities for nighttime faculty to directly supervise or assess this process and enhance trainee communication skills. Similarly, safe transitions between nighttime and daytime teams require high-quality written documentation, with admission or cross-cover notes serving as the only enduring contact after the shift has ended. Nighttime faculty are well situated to use chart-stimulated recall with trainees as a workplace learning method to ensure that documentation is meaningful and that the reasoning embedded within notes is clear and logical.13
Calls to increase direct faculty observation of trainees have existed for decades,14 but the hectic pace of daytime activity in the hospital and the nonclinical schedule demands on daytime faculty make this laudable goal difficult to achieve. Nighttime clinical care is typically devoid of administrative demands, which affords more opportunities for faculty to observe direct patient contact and provide guidance and specific feedback for advanced learners. Attending physician input in real time at night represents a valuable opportunity to model judicious use of resources and cost-conscious care when laboratory, imaging, and consultant availability is limited.15–17
Building a New Model
To realize the potential of nighttime education, training programs will need to develop skilled nocturnal clinician–educators and establish metrics that define success. Transforming “night float” into “nighttime education,” however, requires overcoming several barriers. First, staffing overnight shifts with attending physicians who teach in addition to seeing patients must demonstrate a tangible educational and financial return on investment. Second, it is a challenge to recruit physicians to regular or even periodic nighttime work. Third, the quality of teaching will have to be high and offset the concerns that continuous on-site faculty presence erodes trainee autonomy. Confronting these issues will be critical to the success of a new model for nighttime education.
Supporting return on investment
Developing outstanding clinician–educators who cover nighttime shifts must become an explicit priority for academic and clinical departments. The Clinical Learning Environment Review Program, part of the ACGME’s Next Accreditation System (NAS), will increase alignment between the financial and quality assurance interests of training programs, academic departments, and their partner hospitals.18,19 Nighttime faculty presence will play an important role in fulfilling five of the six focus areas: patient safety, quality improvement, transitions in care, supervision, and duty hours oversight.
Additionally, increasing staffing at night can generate more revenue and boost cost savings. Attending physicians present in the evening can bill for admission services earlier and enhance billing for overnight procedures or intensive cross-cover care. Increased and early attending physician input on patient care decisions could lead to a decrease in errors, lengths of stay, diagnostic testing, and high-cost bed triage.15 Improvement in institutional quality and safety metrics could also justify increased nighttime staffing.
Staffing to enhance education
For specialties like emergency and critical care medicine and obstetrics that require 24/7 in-hospital coverage, staff frequently rotate through daytime and nighttime shifts, although some programs cultivate a cohort of nighttime physicians.20,21 While dedicated nocturnal clinician–educators might be best positioned to enhance nighttime teaching, clinical care, and supervision, we anticipate that many inpatient programs would use a combination of faculty and moonlighters to staff nights. For instance, internal medicine programs are likely to rely on a blend of nocturnists, rotating daytime hospitalists, and nonhospitalists.
Standardizing expectations for educational and supervisory responsibilities is likely more important than a particular staffing model. Although many academic hospitalist groups have on-site nighttime attending physicians, only 38% explicitly define a formal teacher or supervisor role.22 The first step in enhancing nighttime education is delineating how clinical duties assigned to nighttime attending physicians integrate with their supervision and teaching roles. For example, an attending may alternate admissions with the resident, permitting some opportunity to be an available supervisor while simultaneously decreasing trainee clinical duties.
Transforming the learning environment
Nocturnal clinician–educators should have a firm command of multiple teaching modalities, familiarity with nighttime curricula, and skill in balancing supervision with resident autonomy. These elements will be central to transforming the nighttime learning environment.
Teaching effectively at night poses unique challenges. Nighttime learners are sleep deprived, less alert, and express a higher degree of depressed mood.23,24 High clinical workloads for supervising physicians and residents amidst reduced staffing25 require teaching that is mostly integrated into busy workflows rather than delivered in conference rooms.
Faculty development should focus on advancing effective teaching skills, such as meeting residents at the bedside for physical examination of cross-cover patients, analyzing clinical reasoning during an admission, or actively modeling effective communication during nighttime codes. Many of these activities match strategies from the nursing and ambulatory care literature, where busy educators focus successful instruction on microteaching (lasting only minutes) embedded in clinical workflows.26–28 Faculty development should also promote behaviors that facilitate contact and teaching during nighttime hours, such as introductory comments like “I’m not here to sleep” and “my night is more interesting if I hear cases from residents.”
Although workplace learning is the cornerstone of nighttime education, robust curricula are a necessary adjunct to signal the importance of nocturnal learning. Previous studies examining residents’ perceptions of nighttime teaching have shown equivocal results.2,5 In our experience, a short “midnight conference” or “midnight report” has been a well-received teaching modality among trainees and the attending, who briefly reviews an active case or a common clinical topic, such as in-hospital delirium. When the instructor is not available for structured or intensive teaching, curricula can be asynchronously delivered to maintain the rich educational environment.
For example, a multicenter nighttime curriculum, implemented at 89 pediatric and combined medicine–pediatric residency programs, employed 10 online, case-based modules covering medical and communication topics. Learner surveys demonstrated an increase in perceived educational value of nighttime rotations as well as resident confidence and knowledge.29 The finding suggests that residents working night shifts may be situated to complete context-specific online modules, such as the American College of Physicians High Value Care curriculum.30
Oversight and autonomy.
Nighttime attending physician presence marks a shift from traditional supervision, based predominantly on oversight and indirect supervision, to a new blend of direct supervision and indirect supervision with immediate on-site availability. Although this evolution fulfills the NAS’s requirements of enhanced supervision, it may negatively affect learners’ sense of autonomy. Studies suggest, however, that increased attending presence does not diminish trainee or faculty perceptions of autonomy.31–34 Nonetheless, faculty will need to develop communication styles and behaviors that balance patient safety and efficient care with resident independence to facilitate professional growth.35
Measuring and Defining Success
Measuring the impact of a new model is critical to sustainability and continuous improvement. In Table 1, we outline metrics to gauge the success of nighttime education programs. Importantly, training programs and academic promotion systems must recognize educational efforts at night, which currently are largely invisible and underappreciated. This will require rigorous evaluation of nocturnal clinician–educators by trainees and the adaptation of current standards to which daytime clinician–educators are held accountable, including clinical productivity, curriculum development, scholarship, and educational presentations.
There has been a steady call to improve the quality, safety, and efficiency of medical care delivered in hospitals around the clock. The time has come for educators to provide high-quality medical education around the clock as well. Patients, hospitals, and trainees deserve access to a group of physicians who have the ability to transform nighttime clinical work into innovative and effective educational opportunities while delivering high-value care. These clinician–educators, in turn, require financial, workload, and curricular support from employers, training programs, and academic systems to help them succeed. The current training model, in which nearly all of the formal residency education is embedded into the daytime, while faculty and learners simply “survive” night shifts, will no longer suffice.
Acknowledgments: The authors thank the nighttime attendings and faculty at University of California San Francisco Moffitt–Long Hospital and the San Francisco VA Medical Center, whose insights and enthusiasm for nighttime education inspired this Perspective, and Vanessa Thompson, MD, Bradley Sharpe, MD, and Robert Wachter, MD, for their review of an earlier version of this Perspective.
1. Cedfeldt AS, English C, El Youssef R, Gilhooly J, Girard DE. Institute of Medicine committee report on resident duty hours: A view from a trench. J Grad Med Educ. 2009;1:178–180
2. Fletcher KE, Underwood W 3rd, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S. Effects of work hour reduction on residents’ lives: A systematic review. JAMA. 2005;294:1088–1100
3. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF Jr, Saint S. Systematic review: Effects of resident work hours on patient safety. Ann Intern Med. 2004;141:851–857
4. Jagsi R, Weinstein DF, Shapiro J, Kitch BT, Dorer D, Weissman JS. The Accreditation Council for Graduate Medical Education’s limits on residents’ work hours and patient safety. A study of resident experiences and perceptions before and after hours reductions. Arch Intern Med. 2008;168:493–500
5. Reed DA, Fletcher KE, Arora VM. Systematic review: Association of shift length, protected sleep time, and night float with patient care, residents’ health, and education. Ann Intern Med. 2010;153:829–842
6. Shulkin DJ. Like night and day—shedding light on off-hours care. N Engl J Med. 2008;358:2091–2093
7. Luyt CE, Combes A, Aegerter P, et al. Mortality among patients admitted to intensive care units during weekday day shifts compared with “off” hours. Crit Care Med. 2007;35:3–11
8. Mourad M, Adler J. Safe, high quality care around the clock: What will it take to get us there? J Gen Intern Med. 2011;26:948–950
9. Ludmerer KM. Redesigning residency education—moving beyond work hours. N Engl J Med. 2010;362:1337–1338
10. Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: A position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006;144:920–926
11. Burnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med. 2010;181:1159–1160
13. Schipper S, Ross S. Structured teaching and assessment: A new chart-stimulated recall worksheet for family medicine residents. Can Fam Physician. 2010;56:958–959, e352
14. Engel GL. Editorial: Are medical schools neglecting clinical skills? JAMA. 1976;236:861–863
15. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31:2453–2463
16. Smith CDAlliance for Academic Internal Medicine–American College of Physicians High Value; Cost-Conscious Care Curriculum Development Committee. . Teaching high-value, cost-conscious care to residents: The Alliance for Academic Internal Medicine–American College of Physicians Curriculum. Ann Intern Med. 2012;157:284–286
17. Cooke M. Cost consciousness in patient care—what is medical education’s responsibility? N Engl J Med. 2010;362:1253–1255
18. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051–1056
19. Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: The foundation of graduate medical education. JAMA. 2013;309:1687–1688
20. Steele MT, Watson WA. Emergency medicine residency faculty scheduling: Current practice and recent changes. Ann Emerg Med. 1995;25:321–324
21. Takakuwa KM, Biros MH, Ruddy RM, FitzGerald M, Shofer FS. A national survey of academic emergency medicine leaders on the physician workforce and institutional workforce and aging policies. Acad Med. 2013;88:269–275
22. Farnan JM, Burger A, Boonyasai RT, et al.SGIM Housestaff Oversight Subcommittee. Survey of overnight academic hospitalist supervision of trainees. J Hosp Med. 2012;7:521–523
23. Cavallo A, Jaskiewicz J, Ris MD. Impact of night-float rotation on sleep, mood, and alertness: The resident’s perception. Chronobiol Int. 2002;19:893–902
24. Cavallo A, Ris MD, Succop P. The night float paradigm to decrease sleep deprivation: Good solution or a new problem? Ergonomics. 2003;46:653–663
25. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: A survey of hospitalists. JAMA Intern Med. 2013;173:375–377
26. Campbell AM, Nilsson K, Pilhammar Andersson E. Night duty as an opportunity for learning. J Adv Nurs. 2008;62:346–353
27. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5:419–424
28. Wacogne I, Diwakar V. Handover and note-keeping: The SBAR approach. Clin Risk. 2010;16(5):173–175
29. Blankenburg R, Black NP, Maniscalco J, et al. National pediatric nighttime curriculum field test: Assessment of curriculum feasibility and effect on residents’ attitudes, confidence, and knowledge. March 2012 San Antonio, Tex Association of Pediatric Program Directors Presented at https://www.appd.org/meetings/2012SpringPres/PlatformPres1.pdf
. Published March 2012. Accessed October 21, 2013
31. Haber LA, Lau CY, Sharpe BA, Arora VM, Farnan JM, Ranji SR. Effects of increased overnight supervision on resident education, decision-making, and autonomy. J Hosp Med. 2012;7:606–610
32. Phy MP, Offord KP, Manning DM, Bundrick JB, Huddleston JM. Increased faculty presence on inpatient teaching services. Mayo Clin Proc. 2004;79:332–336
33. Farnan JM, Petty LA, Georgitis E, et al. A systematic review: The effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87:428–442
34. Trowbridge RL, Almeder L, Jacquet M, Fairfield KM. The effect of overnight in-house attending coverage on perceptions of care and education on a general medical service. J Grad Med Educ. 2010;2:53–56
35. Farnan JM, Johnson JK, Meltzer DO, et al. Strategies for effective on-call supervision for internal medicine residents: The superb/safety model. J Grad Med Educ. 2010;2:46–52