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Using Team Census Caps to Optimize Education, Patient Care, and Wellness: A Survey of Internal Medicine Residency
Jillian S Catalanotti1, Alpesh N Amin, Steve F Vinciguerra
1J.S. Catalanotti is associate professor, Department of Medicine, and internal medicine residency program director, The George Washington University School of Medicine and Health Sciences, Washington, DC; ORCID: http://orcid.org/0000-0003-3603-1493. A.N. Amin is professor and chair, Department of Medicine, School of Medicine, University of California, Irvine, Irvine, California. S.F. Vinciguerra is business administrator, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, South Carolina. K. Walsh is clinical associate professor, Department of Medicine, The Ohio State University College of Medicine, Columbus, Ohio. J. Gilden is professor, Department of Medicine, chief of endocrinology, and endocrinology fellowship program director, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois. M. Kisielewski is survey and data manager, Alliance for Academic Internal Medicine, Alexandria, Virginia. H.S. Laird-Fick is professor, Department of Medicine, and director of assessment, College of Human Medicine, Michigan State University, East Lansing, Michigan; ORCID: https://orcid.org/0000-0001-9215-8152.
Purpose:
To discover whether internal medicine (IM) residency program directors use lower-than-required caps on general medicine wards, critical care units, and inpatient subspecialty wards; describe justifications for lower-than-required general medicine ward caps and strategies for when caps have been exceeded or the number of patients is a detriment to critical thinking or education; and assess whether caps were associated with program characteristics.
Method:
From August to December 2016, the Association of Program Directors in Internal Medicine surveyed all member program directors about team caps and their effects on the learning environment. Responses were appended with publicly available or licensed third-party data. Programs were categorized by type, size, and region.
Results:
Overall response rate was 65.7% (251/382 programs). Nearly all (244/248; 98.4%) reported caps for general medicine ward teams (mean = 17.0 [standard deviation (SD) = 4.2]). Fewer (171/247; 69.2%) had caps for critical care teams (mean = 13.8 [SD = 5.4]). Fewer still (131/225; 58.2%) had caps for inpatient subspecialty ward teams (mean = 14.8 [SD = 6.0]). Fewer first-quartile programs (0-28 residents) reported having caps on inpatient subspecialty teams (P < .001). Directors reported higher caps compromised education (109/130; 83.8%), patient care (89/130; 68.5%), and/or resident wellness (77/130; 59.2%). Nonteaching services (181/249; 72.7%), patient transfers (110/249; 44.2%), or "backup" residents (67/249; 26.9%) were used when caps are reached or the number of patients is detrimental to critical thinking or education.
Conclusions:
IM program directors frequently exercise discretion when setting caps. Accrediting bodies should explicitly encourage such adjustments and allow differentiation by setting.
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