title: Effects of increased overnight supervision on resident education, decision-making, and autonomy.
abstract: BACKGROUND
  New supervisory regulations highlight the challenge of balancing housestaff supervision and autonomy. To better understand the impact of increased 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
  We established a nocturnist program in July 2010 at our academic, tertiary care medical center. We administered pre-surveys and post-surveys of internal medicine residents on night float rotation during the 2010-2011 academic year. We surveyed residents before and after experiencing the nocturnist program.
  
  
  RESULTS
  Housestaff reported an increase in the clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) and the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001) without a change in decision-making autonomy (4.35 vs 4.45, P = 0.44). Trainees agreed that nocturnist supervision positively impacted patient outcomes (3.79 vs 4.30, P = 0.002). Housestaff contacted attendings more frequently for transfers from outside facilities (2.00 vs 3.20, P = 0.006), during adverse events (2.51 vs 3.25, P = 0.04), prior to ordering invasive diagnostics (1.75 vs 2.76, P = 0.004), and prior to vasopressor use (1.52 vs 2.40, P = 0.004). Residents' fear of revealing knowledge gaps and desire to make decisions independently did not change.
  
  
  CONCLUSIONS
  Increased overnight supervision enhanced the clinical value of the night float rotation, increased rates of attending contact during critical clinical decision-making, and improved perception of patient care. These changes occurred without a decrease in housestaff's perceived decision-making autonomy.
authors.affiliation: Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, San Francisco, California 94110, USA. Lawrence.haber@ucsf.edu
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Haber
authors.forename: Catherine Y
authors.initials: CY
authors.lastname: Lau
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Sharpe
authors.forename: Vineet M
authors.initials: VM
authors.lastname: Arora
authors.forename: Jeanne M
authors.initials: JM
authors.lastname: Farnan
authors.forename: Sumant R
authors.initials: SR
authors.lastname: Ranji
mesh_terms: D000223:Adaptation, Psychological; D002140:California; D002983:Clinical Competence; D003657:Decision Making; D004503:Education, Medical, Graduate / Q000379:methods* / Q000458:organization & administration; D004522:Educational Status; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration*; D005791:Patient Care; D026684:Personal Autonomy; D011787:Quality of Health Care; D057566:Self Report; D013223:Statistics as Topic; D013315:Stress, Psychological; D013663:Teaching; D013997:Time Factors; D014940:Work Schedule Tolerance / Q000523:psychology*; D016526:Workload