Evaluation of a Redesign Initiative in an Internal-medicine Residency

Background: Several organizations have advocated for comprehensive redesign of graduate medical training, but the effect that residency redesign will have on measures of patient satisfaction, resident and intern (trainee) satisfaction, and patient care is unknown.

Methods: We designed an experimental inpatient-medicine service with reduced resident workload comprising two teams, with each team consisting of two attending physicians, two residents, and three interns. Attending physicians, selected for their teaching prowess, supervised the teams throughout the workday and during bedside team-teaching rounds. This experimental model was compared with a control model comprising two teams, with each consisting of one resident and two interns, plus multiple supervising attending physicians who volunteered to participate. Patients were alternately assigned to the experimental teams and the control teams, subject to limits on the number of patients interns are allowed to admit.

Results: Over a 12-month period, 1892 patients were assigned to the experimental teams and 2096 to the control teams; the average census per intern was 3.5 and 6.6 patients, respectively. Overall satisfaction was significantly higher among trainees on the experimental teams than among those on the control teams (78% and 55%, respectively; P=0.002). As compared with the control teams, the experimental teams were not associated with a higher average length of patient stay or readmission rate; adherence to standards for quality of inpatient care was similar in both groups of teams. Interns on the experimental teams spent more time in learning and teaching activities than did interns on the control teams (learning: 20% of total time vs. 10%, P=0.01; teaching: 8% of total time vs. 2%, P=0.006).

Conclusions: As compared with a traditional inpatient care model, an experimental model characterized by reduced trainee workload and increased participation of attending physicians was associated with higher trainee satisfaction and increased time for educational activities.