Patient Perceptions of Who Is Most Involved in Their Care with Successive Duty Hour Limits

Background:

Residency training is grounded in experiential learning, or having residents assume care for a set of patients. Restricted residency duty hours have reportedly led to inpatient attendings playing a larger role in direct patient care. With these changes, it is currently unknown whom patients perceive as the most involved in their hospital care.

Methods:

From 2001 to 2013, all general medicine inpatients were approached for an admission interview and a 30 days post‐discharge phone interview at a single academic medical center. 30‐days after discharge, patients were asked to answer, “Who was most involved in their hospital care?” and were given the options of attending, resident, intern, medical student, nurse, other, or I don’t know. Routine demographics (age, gender, race) were obtained from chart review. Time periods were categorized by duty hour restrictions as pre‐2003, 2003‐2011, and post‐2011. Chi square tests were used to assess associations between demographics, duty hour period, and whom patients named as involved in their care. Multinomial logistic regression was used to test the proportional odds of naming a specific person compared to the attending during the duty hour periods controlling for patient demographics and whether inpatient attending was a hospitalist or not.

Results:

From July 2011 to June 2013, 39,469 patients were enrolled, and 22,750 (58%) could be reached by phone after discharge. Overall, 29% did not know who was most involved, followed by 28% listed the attending, 11% resident and 6% intern. Patients in the oldest age groups were more likely to answer “I don’t know” compared with the youngest patients (25% vs. 36%, p<0.001). The percentage of patients who identified their attending as most involved in their care increased with further duty hours restrictions (pre‐2003 20%, 2003‐2011 29%, post‐2011 37%, p<0.001). With successive duty hour restrictions, the percentage of patients who listed an intern declined in each period (pre‐2003 9%, 2003‐2011 6%, post‐2011 3%, p<0.001) as did the percentage who named any housestaff (resident or intern) (pre‐2003 20%, 2003‐2011 17%, post‐2011 12%, p<0.001). The percentage of patients who responded “I don’t know” decreased with restricted duty hours decreased after 2011 (pre‐2003 32%, 2003‐2011 30%, post‐2011 22%, p<0.001). These associations were not affected by whether the inpatient attending was a hospitalist or not, and they remained significant in multinomial logistic regression.

Conclusions:

The percentage of patients on teaching services identifying their inpatient attending as most involved in their care has more than doubled with increasing resident duty hours. While the rates of patients who identified housestaff as most involved in their care was low initially, it has further declined after duty hours. These results have implications for residency trainees, as well as inpatient attendings who likely assume a more direct role in patient care with a greater workload.