Development of an institutional “good practices” policy for resident and attending-physician on-call responsibilities
Matthew Lipinski, MD, Shahbaz Syed, MD, and Jerry M. Maniate, MD
On-call coverage by resident physicians is common in academic hospitals, but the interaction between residents and supervising attending physicians varies. Responsibilities are often not clearly defined, which contributes to unclear expectations on the part of both. We developed an institutional “on-call responsibilities” guideline for both residents and attending physicians using a nominal group technique to gain consensus with multiple institutional stakeholders. Three focus groups engaged 31 clinical stakeholders in the development of concise guidelines that include 12 resident responsibilities and 12 attending-physician responsibilities that can be implemented while on-call. Using the nominal group technique allowed us to engage a large number of stakeholders and generate a robust guideline that could be easily operationalized to create a consistent expectation of responsibilities while on call and promote patient safety. It can also potentially reduce resident burnout. This quality-improvement project generated a list of concrete responsibilities that can be used in other centres and provides a robust approach to developing similar policies in other clinical contexts.
KEY WORDS: on call, nominal group technique, quality improvement, residency
Lipinski M, Syed S, Maniate JM. Development of an institutional “good practices” policy for resident and attending-physician on-call responsibilities: a nominal group technique quality-improvement project. Can J Physician Leadersh 2022;8(4):127-132 . https://doi.org/10.37964/cr24760
In any academic hospital where postgraduate medical education (PGME) occurs, resident physicians are often required to provide on-call medical care to patients admitted to their services while also being responsible for seeing new consultations from other services. Although these residents have a supervising attending physician, who is the “most responsible physician,” the dynamic between residents and attending physicians while on call varies. In a recent survey of 126 residents at our academic hospital, 71% of respondents were either unsure or did not know of a formal policy regarding contacting attending physicians while on call. In addition, 31% of those respondents cited fear of appearing uncertain and 45% cited fear of appearing incapable as barriers to contacting their attending physician while on call. This revealed a gap in providing expectations of behaviour for both residents and attending physicians at our hospital. Further, medical education emphasizes creating psychologically safe environments for our trainees. Ensuring standard expectations and communication with on-call staff can help to foster that culture.
Although the literature contains information on desirable attributes of attending physicians while on call,1,2 there is a lack of research into their application at an institutional level. To support our residents and attending physicians, we sought to develop a “good practices” institutional policy delineating responsibilities that could be used to develop specific on-call policies for each clinical department or residency training program at our institution, The Ottawa Hospital, which is affiliated with the University of Ottawa.
Between fall 2020 and spring 2021, we held three focus groups, structured using the nominal group technique consensus format,3 which involves a specific structure of engaging with stakeholders. To generate the responsibilities identified in this policy, we sent an invitation to a broad group of stakeholders: clinical department heads, program directors, departmental vice chairs of education, and chief residents from most residency programs. This group was selected to try to ensure engagement at higher levels of leadership when the final policy was produced.
Nominal group technique was chosen as it allows for the generation of a greater number of ideas, more balanced input from members, and more structured consensus building than traditional brainstorming. The format of the nominal group technique focus group involved presentation of our main question (What should be specific responsibilities for attendings and residents while on call?), followed by individual brainstorming of specific ideas. Subsequently, a round-robin discussion involved the creation of a complete list. A discussion was held to clarify and condense certain responses as a group, with subsequent private voting on the relative importance of each idea.3
A final list was prepared of all responsibilities that were voted on by at least one group member. Voting was done by asking participants to rank a fixed number (5 responsibilities for residents and 5 responsibilities for attendings) in order of importance for each group. This list of “good practice guidelines” was then sent out to the initial stakeholder groups for a final round of voting to establish the top responsibilities for both attending physicians and residents.
Ethics approval for our project was provided by the Ottawa Health Sciences Network Ethics Review Board through an exemption letter for a quality-improvement project.
In the focus groups, we engaged with 12 participants (6 medical trainees and 6 attending physicians). They identified 28 unique resident responsibilities and 27 unique attending-physician responsibilities. Subsequently, 16 resident responsibilities and 18 staff responsibilities were voted on by participants and included in the final survey to all stakeholders (Table 1).
The final survey was sent to 240 stakeholders, 31 of whom replied for a response rate of 12.9%. Like the focus-group participants, these respondents were asked to provide a weighted ranking list to determine the relative importance of the responsibilities. Survey instructions are available on request. An arbitrary maximum of 12 unique responsibilities for both residents and attending physicians was decided on to ensure that the final policy was sufficiently concise. The final list of responsibilities can be found in Table 2 along with an associated infographic (Figure 1).
The proposed policy, including the final list of responsibilities, was then introduced to the University of Ottawa Faculty of Medicine postgraduate executive committee (members consist of the vice dean of PGME along with residency-training program directors) followed by the hospital’s medical affairs advisory committee (members consist of a subset of department heads from the medical affairs committee) for input before final presentation to the medical affairs committee for approval of the policy.
Kennedy and colleagues4 identified clinical, supervisor, and trainee factors that determine a trainee’s decision to obtain clinical support from their staff. Specifically, the availability and approachability of a staff supervisor were cited as key considerations of a resident deciding when and how frequently they contacted their supervisor while on call. Multiple studies have shown discordant opinions between attending physicians and medical trainees regarding when it is appropriate to contact supervising staff.5,6 Ultimately, a systematic review7 found that improved supervision of learners (i.e., promoting regular communication, soliciting contact when uncertain, reassuring residents not to be afraid to call) resulted in improved patient safety. Residents who felt unsupported by the relationship with their attending physician reported higher levels of emotional exhaustion and burnout.8
These studies indicate that a resident’s decision to contact their attending while on call is multi-factorial and not solely based on clinical aspects, but also the characteristics of the attending themselves. Our project provides a process to develop clear hospital policies to standardize that interaction and empower residents to contact their attending supervisor when clinically indicated.
Strengths and limitations
The strength of our study lies in the novelty of the development of an on-call responsibilities guideline, using the nominal group technique for consensus building and then operationalizing at an organizational level. This project outlines how to engage with stakeholders from diverse backgrounds to generate a unified guideline. Both the process for developing the guideline and the content itself may be easily adapted and generalized to other institutions to meet their individual needs.
This process does have some limitations. A large number of stakeholders were contacted to ensure that none were missed, but the response rate was low. A response bias is present, as there was only a single follow up of stakeholders who were initially contacted and only those who were interested in engaging in the process were included. In addition, the nominal group technique, by definition, is the generation of ideas and consensus among stakeholders. As such, the generalizability of the output may be limited as it is significantly influenced by the local context.
Through the engagement of multiple stakeholders across our academic hospital (The Ottawa Hospital), using a consensus-based nominal group technique, we generated a list of concrete responsibilities to provide a standardized approach to the trainee–attending relationship while on call. The findings of this project could be used by other institutions to develop their own policies with respect to on-call responsibilities of trainees and attendings to better enhance patient safety and trainee psychological safety. This project is part of a larger plan-do-study-act cycle, in which we are assessing the current on-call culture in our organization and a post-implementation survey is planned to assess the impact of a formalized on-call policy.
The interaction between residents and supervising attending physicians at academic teaching hospitals varies and expectations are often unclear.5 In a recent survey of residents at our hospital, 71% were not aware of a formal policy for contacting their attending physician while on call.
Using a nominal group technique, we developed a “good practices” consensus guideline with the engagement of multiple stakeholders. This resulted in an institutional policy that promotes patient safety and consistent expectations of responsibilities while on call.
This quality-improvement project provides a road map for the development of consensus policies in other clinical contexts while also creating a list of concrete responsibilities that can be easily adopted in other centres.
Department and organizational leaders should review whether they have any formal policies guiding supervision of medical learners while on call and, if required, consider developing a similar policy based on their local context.
1. Busari JO, Weggelaar NM, Knottnerus AC, Greidanus PM, Scherpbier AJJA. How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting. Med Educ. 2005;39(7):696-703. https://doi.org/10.1111/j.1365-2929.2005.02190.x
2. Farnan JM, Johnson JK, Meltzer DO, Harris I, Humphrey HJ, Schwartz A, et al. Strategies for efective on-call supervision for internal medicine residents: the superb/safety model. J Grad Med Educ 2010;2(1):46-52. https://doi.org/10.4300/JGME-D-09-00015.1
3. Dunham RB. Nominal group technique: a users’ guide. Madison, Wisc.: University of Wisconsin; 2006. Available: https://tinyurl.com/mw6fw8jr
4. Kennedy TJT, Regehr G, Baker GR, Lingard L. Preserving professional credibility: grounded theory study of medical trainees’ requests for clinical support. BMJ 2009;338:b128.
7. Farnan JM, Petty LA, Georgitis E, Martin S, Chiu E, Prochaska M, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med 2012;87(4):428-42. https://doi.org/10.1097/ACM.0b013e31824822cc
8. Prins JT, Gazendam-Donofrio SM, Dillingh GS, van de Wiel HBM, van der Heijden FMMA, Hoekstra-Weebers JEHM. The relationship between reciprocity and burnout in Dutch medical residents. Med Educ 2008;42(7):721-8. https://doi.org/10.1111/j.1365-2923.2008.03041.x
Matthew Lipinski, MD, MHA, FRCPC, is an emergency physician at The Ottawa Hospital and an assistant professor with the University of Ottawa.
Shahbaz Syed, MD, FRCPC, is an emergency physician at The Ottawa Hospital and an assistant professor with the University of Ottawa.
Jerry M. Maniate, MD, MEd, FRCPC, FACP, is a general internist at The Ottawa Hospital, an educator at the University of Ottawa, and a researcher at The Ottawa Hospital Research Institute.
Author attestation: Dr. Lipinski was the primary writer of the manuscript and the main creator of on-call policy. Dr. Syed edited the manuscript and developed the infographic. Dr. Maniate edited the manuscript and developed the quality-improvement initiative and process. All authors approved the final version of the article.
No specific grants or funding was received for this project. The authors declare no competing interests.