Assessing the Night Float Educational Experience

Night float (NF) rotations are a common mechanism used in residency training programs to provide hospital service coverage in compliance with mandated residency duty hour regulations. This structure was pioneered in residency training in the late 1980s in an effort to mitigate resident fatigue. Since implementation of the Accreditation Council for Graduate Medical Education residency work-hour restrictions in 2003 and 2011, NF has been widely adopted in most residency programs. Despite ample experience with this system, its effect on the quality of resident education and training remains poorly defined.1 Resident training must balance the often dichotomous pursuits of service and education. In this conceptual divide, NF is a practical necessity to meet service, rather than educational requirements, whereas regular work-day rotations provide both service and education. However, NF may have nontraditional, secondary educational benefits. To assess the educational effect of NF service, we conducted a survey of general surgery residents’ NF perceptions. This was a quality improvement survey of general surgery residents at the University of Maryland Medical Center, the hospital affiliated with the University of Maryland School of Medicine and the R Adams Cowley Shock Trauma Center. The surgery residency program has a complement of six categorical residents per year, with a mandatory 2-year research requirement after postgraduate year (PGY) 2. When including 10 nondesignated preliminary residents and two full-time PGY-1 residents for urology, the total complement is 54 residents. Our program’s NF experiences include four PGY-1 and two PGY-3 rotations, which are typically six 12-hour shifts per week. Each PGY-1 NF rotation includes cross-coverage for multiple services. The PGY-3 NF experience provides consult and intensive care unit coverage for core general surgery services, and is the highest ranking resident on duty in the hospital at night. Participation was voluntary, and no identifying data were linked surveys to individual residents. The survey was performed at the end of the 2013 to 2014 academic year using an online instrument. Questions were scored on a 5-point Likert scale, with the addition of several questions with free-text responses. The survey items are listed in Figure 1. Twenty-eight of 54 residents (52%) responded to the survey. The majority (82%) had been on at least one NF rotation, and 50 per cent had at least three rotations. Between lower (PGY-1, 2, and research) and upper (PGY 3, 4, and 5) level residents, response rates (59% vs 41%, P4 0.21) and average number of NF rotations (3 vs 2, P4 0.28) were not significantly different. Several positive attributes of a NF rotation were noted. A total of 92 per cent met duty hour requirements during NF. Of all, 58 per cent agreed or strongly agreed that NF has positive overall educational value. Additional, self-reported positive aspects included the opportunity for increased autonomy, ability to focus on clinical care and a more regular schedule. However, only 22 per cent of residents enjoyed NF to any degree. Although intended to reduce fatigue, adequate rest and work/life balance were reported in only 36 and 18 per cent of residents, respectively. Furthermore, a minority (15%) reported that there was an adequate balance between service and education. Of all, 11 per cent had satisfactory evaluation of their admissions by a supervising resident or attending, and just 4 per cent had adequate operative experience during NF. NF facilitates surgical service coverage and duty hour compliance, although traditionally at the expense of decreased involvement in formal educational activities. This survey of residents’ perceptions of NF rotations indicates that our current system needs to be Address correspondence and reprint requests to Adam S. Weltz, M.D., Department of General Surgery, University of Maryland Medical Center, 29 South Greene Street, 643A, Baltimore, MD 21201. E-mail: aweltz@smail.umaryland.edu.