Physician Burnout Decreases With Shorter Trainee Rotations

Emma Hitt, PhD

December 05, 2012

Shorter, 2-week clinical rotations appear to be similar to 4-week rotations with respect to patient revisits within 30 days (a measure of patient care) and may decrease burnout and stress among attending physicians on the internal medicine wards, who are training house staff and medical students, according to a new trial.

Brian P. Lucas, MD, from the Department of Medicine, Cook County Health and Hospitals System and Rush Medical College, Chicago, Illinois, and colleagues report their findings in an article published in the December 5 issue of JAMA.

According to the researchers, although some variation exists among hospitals, there is a current trend for attending physicians to be assigned to ward teams for the purposes of training for only 2 continuous weeks, which is approximately half the previous standard duration.

"Both trainees and educational leaders have decried short rotations as disruptive because they truncate student-teacher relationships," Dr. Lucas and colleagues write. However, they add, "if shorter rotations can lessen attending physician burnout, they may improve physicians' relationships with patients and the quality of care that patients receive."

Using a cluster-randomized crossover noninferiority design, with attending physicians as the unit of crossover, the current study sought to compare 2- and 4-week rotations with respect to a variety of measures. The primary outcome was the unplanned revisit rates among patients within 30 days of hospital discharge, which included visits to the emergency room or urgent ambulatory care clinic, as well as admissions to the same hospital or transfers from another hospital.

The researchers also assessed how rotation durations affected trainees' ratings of attending physicians' performance and the self-rated psychological health of attending physicians.

Data from 8892 patients were evaluated; among those, 2437 unplanned revisits were recorded. The percentage of patients having an unplanned revisit was similar, at about 21%, for both groups (mean difference, −0.3%; 95% confidence interval [CI], −1.8% to 1.2%; P = .007 for noninferiority). The average length of stay, about 67 hours, was also similar for the 2- and 4-week rotation groups.

In contrast, in the shorter rotation group, attending physicians were more likely to score lower in their ability to fairly evaluate trainees. The house staff was twice as likely to rate attendings as less than perfect in their ability to fairly evaluate the house staff (40.9% vs 27.5% in the 2-week vs 4-week groups, respectively; adjusted odds ratio [OR], 2.10; 95% CI, 1.50 - 3.02; P < .001).

Likewise, medical students in shorter rotation groups were also more likely to rate their attendings as less than perfect in their ability to fairly evaluate the medical student than their counterparts in the longer rotation groups (81.5% vs 69.1%; adjusted OR, 1.41; 95% CI, 1.06 - 2.10; P < .045). Adjustments were made for ward team, crossover period, and the relatedness of grouped measures.

Compared with those in the 4-week rotation, however, attending physicians in the 2-week group were less likely to report higher scores of burnout severity (16.4% vs 35.1%; adjusted OR, 0.39; 95% CI, 0.26 - 0.58; P < .001) and emotional exhaustion (18.8% vs 36.5%; adjusted OR, 0.45; 95% CI, 0.31 - 0.64; P < .001).

Study limitations include use of a single center, subjectivity of the trainees' rankings of attending physicians, lack of objective validation of the burnout measurements, and inability to blind the attending physicians and trainees.

"As a result of these present findings...attending physicians at our hospital now voluntarily choose between 2- or 4-week rotations," the authors note.

They add that if the "projected trend toward shorter rotations continues, a trial of 1-week rotations may be needed. If so, direct testing of trainees' skills and behaviors would be a more relevant measure of attending physician teaching performance than trainees' perceptions."

Support for this study was provided by the Foglia Family Foundation. The authors have disclosed no relevant financial relationships.

JAMA. 2012;308:2199-2207. Abstract