Learning on the late shift
Training programs and hospitalists are working to make night coverage more educational.
The biggest obstacle to teaching students and trainees during overnight hospital shifts isn't complicated. “People are tired at night,” said ACP Resident/Fellow Member Holland Kaplan, MD, a clinical ethics fellow and instructor of medicine at Baylor College of Medicine in Houston.
Adding to the challenge, physicians, including trainees, generally have more patients under their watch overnight. “During the day, an intern would cover only up to seven or eight patients,” said ACP Member Jawad Al-Khafaji, MD, MSHA, an assistant professor of medicine at the University of Michigan in Ann Arbor. “At night, an intern would be covering two teams, and if each team has up to 14 patients, the maximum number of patients is 28.”
However, academic hospitalists are increasingly finding motivation and methods to overcome everyone's weariness and busyness and provide more structured education at night. They are also sharing their models, which range from self-directed modules to quick chalk talks to late-night conferences, to encourage others to make the most of night shifts.
“It is so rewarding to be teaching at night,” said ACP Member Alexander Rittenberg, MD, an academic nocturnist and associate program director for internal medicine at Virginia Commonwealth University (VCU) in Richmond. “It is certainly an acquired taste. … Is it worthwhile to teach at night? Absolutely.”
One of the more formal nighttime education initiatives began at VCU and was described by Dr. Al-Khafaji and colleagues in an article published by the Southern Medicine Journal in 2020.
“Most of the conferences happen during the daytime and for good reason,” he said. “But we wanted to mirror at least part of that. That's why we did midnight report.”
Once or twice a week at around midnight (or often more like 11 p.m., Dr. Al-Khafaji noted), the physicians on the night shift gathered to discuss a recent interesting case, presented by the resident who admitted the patient. “The other residents would participate, asking questions, contributing to the differential, and then I or whichever nocturnist was on duty that night would help in the background, providing an educational contribution,” he said.
Midnight report is naturally a much smaller gathering than a morning report, which Dr. Al-Khafaji found to be a benefit. “From my experience, there was engagement from almost everyone, as opposed to during the daytime you may have a lot of residents sitting in the room and some of them may be quiet.”
One challenge was scheduling and conducting the meeting when the shift was busy. “We did have some nights where to get [residents] to midnight report was a bit difficult, and when they came they were so busy thinking about their admissions,” he said.
For the article, Dr. Al-Khafaji and colleagues surveyed residents after implementation of midnight report. More than two-thirds had a positive view of the night rotation's educational environment and believed they were getting evidence-based education. The researchers didn't have any equivalent preintervention numbers, but “compared to historical surveys of night rotation, that was a good, positive response,” he said.
Adding the conference was also a step toward changing the general perception of night float, Dr. Al-Khafaji believes. “The culture has instilled that ‘I'm covering the patient of the day team overnight temporarily so I'm just going to put out fires,’ as opposed to ‘I'm going to assume accountability and continuity of care, and these are my patients,’” he said. “This has been the case in many residencies, including admittedly mine until we implemented our nightly educational program, and I see this all over academic institutions.”
Naturally, physicians are less likely to think of night work as a temporary fill-in if they've made it their career.
“What I have found is that more and more the faculty who work at night are dedicated nocturnists,” said Dr. Kaplan. “When they're hired, sometimes they're told upfront that there is an expectation of teaching at night.”
In a 2019 survey of 148 U.S. nocturnists, 28% reported that medical education was one of their responsibilities, although that doesn't necessarily mean they all have formal faculty roles, noted ACP Member Kathleen Atlas, MD, who was lead author of the study, published by Hospital Practice in June 2021.
“The opportunities for teaching could come from, say, a code situation that the nonteaching attending responds to. If it's with the learner's patient, then they can debrief after, or go through stepwise, ‘What's going on with this patient? What are we thinking about?’” said Dr. Atlas, a hospitalist and deputy service chief for nights at Memorial Sloan Kettering Cancer Center in New York City.
Informal bedside education like this is valued by residents, she noted. “Most learners on the night rotation do feel that they learn a lot at night just because they're covering a large volume of patients and there's a lot of emergencies.” However, she also thinks nighttime encounters could be better used for teaching.
“A group of academic nocturnists from different institutions are specifically trying to work on a curriculum …. We're trying to create these little bite-sized chalk talks that a nocturnist can easily refer to and pull up based on whatever they're seeing with their patients and their residents,” Dr. Atlas said.
Dr. Rittenberg is another one of the nocturnists working on this project. “To be successful, educators at night need to adapt their teaching to the environment. One of the challenges is the unpredictability in what we encounter,” he said. “Having a quick-hits repository of teaching topics at hand that they can deliver in real time in response to a clinical scenario helps further the educational value.”
The nocturnists at his hospital are pursuing ways to add educational value to their time with residents. “Our director for point-of-care ultrasound is also one of the academic nocturnists,” Dr. Rittenberg said. “We end up doing scanning sessions with our residents on a regular basis. They acquire their own images. They receive feedback in real time.”
When designing nighttime education, faculty should keep the inherent challenge of trainee sleepiness in mind, he noted. “It's tough to retain information,” Dr. Rittenberg said. “One of the things that I do is at the end of the night, I send out an article based on a clinical encounter my residents have had with my teaching points on it, so they can take this away from the rotation and read it at their leisure.”
By residents, for interns
Turning downtime into educational time was a motivator of another nocturnal initiative. “When I was a resident, education at night was kind of lacking. Since we did spend a decent amount of time working at night, I thought it would be helpful to have some structured formal education,” said Dr. Kaplan.
When she became a senior resident, Dr. Kaplan worked with colleagues to develop a night float curriculum for interns. They created 12 modules, which the learners could complete alone or with a resident or attending, and reported the positive effects on intern confidence in the August 2022 Southern Medical Journal.
“A lot of it did end up being self-initiated, and interns actually found that they enjoyed doing it on their own. They did find it helpful to have a senior resident or faculty member participating, but if you're relying on other people to be involved, then it's less likely it will happen,” Dr. Kaplan said.
Modules covered topics such as altered mental status, hypotension, arrhythmias, and sepsis and antibiotic escalation and included cases, explanations, and board-style questions. “I do think that the process of creating the curriculum is helpful, but it's a very arduous process,” she said. “We'd be happy to share our curriculum.”
Although the interns could complete the modules by themselves, faculty buy-in was key to adoption. “I remember going around to each of our hospitals to the faculty meetings and saying, ‘Hey, here's the curriculum, here's how you can go through it,’” said Dr. Kaplan, “making sure everyone knows about it because it's very easy to let it just go by the wayside during a busy rotation at night.”
Organizing the information around cases helped keep the attention of tired trainees. “If they're doing it with a faculty member or senior resident there can be back-and-forth engagement, asking questions and coming up with differentials,” she said.
The push to make nights more educational has been growing ever since the Accreditation Council for Graduate Medical Education set the 80-hour resident work limit in 2003, Dr. Kaplan noted. “Increasingly programs have been restructuring over the past 15 years or so to night float systems. The transition is ongoing and the structures continue to change,” she said.
At Mount Sinai Hospital, internal medicine night float has been expanded to include medical students in recent years, initially for five-night stints.
“After clerkships were suspended in the spring of 2020, we had an unprecedentedly large number of students joining the clerkships the following academic year, and we needed to distribute those students across time and space in a way that they could take care of patients and learn experientially,” said Horatio (Teddy) Holzer, MD, assistant professor and co-director of curriculum at Icahn School of Medicine at Mount Sinai.
Patients' arrivals are distributed across the day, so having students in the hospital later opened up more opportunities to assess patients. “During the daytime across a six-week clerkship, students were doing, maybe if they're lucky, one admission of an undifferentiated patient,” said Dr. Holzer. “The first couple of hours are a time when you learn a ton about the patient, collect an amazing amount of information, and really delve into the clinical reasoning.”
To see whether students agreed that this learning opportunity outweighed the loss of sleep, Dr. Holzer and two of his students at the time conducted a survey and reported their results in a concise research report published by the Journal of General Internal Medicine on Dec. 1, 2022.
Out of more than 100 students, two-thirds had presented at least four admissions during night float and thought there was educational benefit in the rotation, particularly from performing overnight admissions, presenting histories and physicals, and improving oral presentation skills.
The expected downside did crop up, noted co-lead author Jessica Tran, an ACP Medical Student Member and now a fourth-year student at Mount Sinai. “Over 30% of students felt physical exhaustion, mental exhaustion,” she said. “Starting this past academic year, we shortened the clerkship from five days to four days to help with the adjustment from days to nights and back.”
Some practice at making that adjustment is another potential benefit of the program, according to co-lead author Matthew Fine, MD, currently a resident at Columbia University in New York City.
“As someone who is now an intern and spending a lot of time at night in the hospital, I actually look back very fondly on that week. I showed myself that you can make the switch back and forth and a lot of people have done it and a lot of people will do it, and that's part of being a medicine trainee,” he said.
Some students may have more trouble with overnight work, and it's important that programs have support ready if they need it, Dr. Holzer added. “We have 24/7 support systems here. There's always a provider who's available on a 24-hour hotline as well as apps to help adjust day-night cycles, faculty advisors,” he said. “Any experience can differentially affect different groups of students.”
All of the experts agreed that nighttime education needs to be individualized by institution. “I think every hospital sets up their nights a little differently,” said Dr. Atlas. “Tailoring the education to the particular setting is probably the best way to maximize learning at night.”
There are a few universal strategies to help make all kinds of new programming effective and engaging, though, according to Dr. Al-Khafaji. “Make sure to structure it, then set expectations, and also always add pizza or some food,” he said.