Effects of 2- vs 4-Week Attending Physician Inpatient Rotations on Unplanned Patient Revisits, Evaluations by Trainees, and Attending Physician Burnout
Authors: Brian P. Lucas, William E. Trick, Arthur T. Evans, Benjamin Mba, Jennifer Smith, Krishna Das, Peter Clarke, Anita Varkey, Suja Mathew, Robert A. Weinstein
Journal: JAMA (2012)

<h3>Context</h3>Data are sparse on the effect of varying the durations of internal medicine attending physician ward rotations.<h3>Objective</h3>To compare the effects of 2- vs 4-week inpatient attending physician rotations on unplanned patient revisits, attending evaluations by trainees, and attending propensity for burnout.<h3>Design, Setting, and Participants</h3>Cluster randomized crossover noninferiority trial, with attending physicians as the unit of crossover randomization and 4-week rotations as the active control, conducted in a US university-affiliated teaching hospital in academic year 2009. Participants were 62 attending physicians who staffed at least 6 weeks of inpatient service, the 8892 unique patients whom they discharged, and the 147 house staff and 229 medical students who evaluated their performance.<h3>Intervention</h3>Assignment to random sequences of 2- and 4-week rotations.<h3>Main Outcome Measures</h3>Primary outcome was 30-day unplanned revisits (visits to the hospital's emergency department or urgent ambulatory clinic, unplanned readmissions, and direct transfers from neighboring hospitals) for patients discharged from 2- vs 4-week within-attending-physician rotations. Noninferiority margin was a 2% increase (odds ratio [OR] of 1.13) in 30-day unplanned patient revisits. Secondary outcomes were length of stay; trainee evaluations of attending physicians; and attending physician reports of burnout, stress, and workplace control.<h3>Results</h3>Among the 8892 patients, there were 2437 unplanned revisits. The percentage of 30-day unplanned revisits for patients of attending physicians on 2-week rotations was 21.2% compared with 21.5% for 4-week rotations (mean difference, –0.3%; 95% CI, –1.8% to +1.2%). The adjusted OR of a patient having a 30-day unplanned revisit after 2- vs 4-week rotations was 0.97 (1-sided 97.5% upper confidence limit, 1.07; noninferiority P = .007). Average length of stay was not significantly different (geometric means for 2- vs 4-week rotations were 67.2 vs 67.5 hours; difference, –0.9%; 95% CI, –4.7% to +2.9%). Attending physicians were more likely to score lower in their ability to evaluate trainees after 2- vs 4-week rotations by both house staff (41% vs 28% rated less than perfect; adjusted OR, 2.10; 95% CI, 1.50-3.02) and medical students (82% vs 69% rated less than perfect; adjusted OR, 1.41; 95% CI, 1.06-2.10). They were less likely to report higher scores of both burnout severity (16% vs 35%; adjusted OR, 0.39; 95% CI, 0.26-0.58) and emotional exhaustion (19% vs 37%; adjusted OR, 0.45; 95% CI, 0.31 to 0.64) after 2- vs 4-week rotations.<h3>Conclusions</h3>The use of 2-week inpatient attending physician rotations compared with 4-week rotations did not result in an increase in unplanned patient revisits. It was associated with better self-rated measures of attending physician burnout and emotional exhaustion but worse evaluations by trainees.<h3>Trial Registration</h3>clinicaltrials.gov Identifier: NCT00930111