Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey
Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey
Eric N. Goren 2
Debra S. Leizman 1
Jeffrey La Rochelle 0
Jennifer R. Kogan 2
0 Uniformed Services University of the Health Sciences , Bethesda, MD , USA
1 Case Western Reserve School of Medicine , Cleveland, OH , USA
2 Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
BACKGROUND: Since the 2011 Accreditation Council of Graduate Medical Education (ACGME) work hour rules for residents were implemented, 24-30 h call for interns has been replaced by shift work, including night-float. The impact of these changes on undergraduate medical education experiences in internal medicine has not been described. OBJECTIVE: We aimed to determine the current status of medical students' overnight experiences in Internal Medicine clerkships and sub-internships, and to assess internal medicine educators' perceptions of the importance of overnight work during internal medicine rotations. DESIGN AND PARTICIPANTS: In May 2014, the Clerkship Directors in Internal Medicine (CDIM) conducted its annual survey. Twenty-eight questions about student participation in overnight work and perceptions of the importance of overnight work (rated on 1-5 Likert scale, 1=very unimportant and 5=very important) were included. Descriptive statistics were used to summarize responses. Free text results were analyzed qualitatively. KEY RESULTS: The response rate was 78 %. A minority of respondents reported students having any overnight experience during the clerkship (38.7 %) or the subinternship (40.7 %). Only 5 % of respondents reported having students assigned to night-float rotations outside of clerkships or sub-internships. Respondents agreed that overnight experiences were more important during the sub-internship than the clerkship, 4.0±1.1 vs. 3.2± 1.2, p<0.001. Admitting new patients, following their course and responding to emergencies were rated as important overnight tasks for both clerkship and subinternship students. CONCLUSIONS: Overnight experiences offer students additional educational opportunities. Clerkship directors felt that the overnight experience for the sub-intern in particular was an important chance to practice providing emergency cross coverage and other intern roles. In the era of ACGME duty hours, there is a need to further examine whether there is a role for increased overnight hospital experiences for medical students.
overnight; medical student; education; shift; duty hours; J Gen Intern Med 30(9); 1245-50 DOI; 10; 1007/s11606-015-3405-4 © Society of General Internal Medicine 2015
At the end of the 19th century, the original Bresident physician^
resided at the hospital and was responsible for patients 24 h per
day, 7 days per week.1 Residency training evolved into a system
where teams of doctors stayed in the hospital for 24–36 h shifts
(traditional overnight call) every third or fourth night.2 Medical
students were assigned to work with residents embracing a
philosophy that students should be apprentices, immersed in
patient care with gradually increasing responsibility until the
student becomes resident and teacher.3
In 2003, the Accreditation Council for Graduate Medical
Education (ACGME) established new duty hour regulations
that limited residents to an 80-h work week, limited
continuous on-site duty, including in-house call, to 24 consecutive
hours, prohibited residents from assuming care of new patients
following 24 h of duty, and required at least 1 day off per
week.4,5 An unofficial shift in medical students’ work hours
followed. The 1994 Liaison Committee on Medical Education
(LCME) Dean’s survey reported that 86 % of medicine
clerkships required students to take overnight call; this decreased to
80 % by 2002. By 2009, only 61 % of medicine clerkships
included overnight call.6 In 2011, ACGME duty hour
restrictions limited interns to less than 16 continuous hours of patient
care. Resident schedules began to incorporate more shift work
including night shifts (also known as night-float, where
residents work consecutive 10–14 h overnight shifts) as an
alternative to traditional call.7,8 The night-float schedules result in
different allocations and timing of admissions to resident
teams. For example, more than 40 % of internal medicine
hospital admissions are admitted by the night-float team and
handed off the next morning.9,10This change in the inpatient
residency training environment has the potential to impact
medical students whose clinical experiences historically
focused on admitting new patients complemented by resident
To our knowledge, the prevalence of overnight experiences
and their structure has not been described in Internal Medicine
undergraduate medical education (UME) since the 2011 duty
hours were implemented. Additionally, there has been little
research on the importance of overnight experience in
developing medical students’ clinical skills. To date, most
publications have been editorials or single institution studies6,11–19
that highlight potential pros and cons of overnight
experiences. Our survey was undertaken to better understand the
status of student overnight experiences during core Internal
Medicine rotations, and to determine whether Internal
Medicine educators perceive overnight experience as an important
component of training for undergraduate medical students.
The Clerkship Directors in Internal Medicine (CDIM) is the
organization of educators teaching internal medicine to
medical students. The CDIM annually conducts a survey of its
institutional members on topics relevant to teaching Internal
Medicine to medical students. Each institution nominates its
own institutional member to respond on behalf of the
institution on educational matters or surveys. Per CDIM Bylaws, this
individual shall be the Clerkship Director or other qualified
educator designated by the Chair (or equivalent) of those
Departments of Internal Medicine of LCME /Committee on
Accreditation of Canadian Medical Schools accredited
medical schools of the United States of America, the
Commonwealth of Puerto Rico, and Canada (AAIM.
Survey Development and Implementation
Each fall, CDIM members may submit survey questions
for potential inclusion in the annual survey.20 The
CDIM Research Committee selects questions for
inclusion based on clarity, quality, appropriateness, and
importance to the CDIM mission. A series of questions
addressing student participation in overnight experiences
during the medicine clerkship or sub-internship were
selected for inclusion in the annual survey. Questions
were edited and revised before being presented to CDIM
Council, who provided further revisions and final
approval. The online survey instrument underwent pilot
testing by members of the Research Committee and
Council, with edits for optimal flow and clarity made
prior to launch. In May 2014, CDIM conducted its
annual, online, confidential survey of its 121 US and
Canadian member medical schools. The designated
institutional member from each medical school was
invited by email to participate. Non-responders were
contacted up to three additional times by email and once
by telephone. The Institutional Review Board at the
Washington DC Veterans Affairs Medical Center
exempted this study.
One section of the 2014 CDIM Survey included 28 questions
about overnight experiences in the Internal Medicine clerkship
and sub-internship (survey available as online appendix).
Questions first addressed the prevalence of overnight
experiences in clerkships and sub-internships. If overnight
experiences were present, respondents were asked who students
worked with and what activities were performed. There was
a question about the overall perceived importance of overnight
experiences. Eight additional questions asked about the
perceived importance of different aspects of overnight
experiences (i.e., admitting new patients, following the initial course
of newly admitted patients, observing the management of
patients, responding to cross cover, observing role of intern/
resident and attending, and preparing for future roles). These
questions were rated on a 1–5 interval Likert scale (5 very
important, 4 important, 3 neutral, 2 unimportant, 1 very
unimportant). There was an open-ended question about
why there should or should not be support of overnight
experiences. The survey also included demographic
questions (see online appendix for full survey).
Descriptive statistics were used to summarize demographic
data and outcome measures. Chi-squared analysis was used to
determine differences between the frequency of medical
student roles on the core clerkship and sub-internship overnight
experiences. A student’s t test was used to determine
differences in perceived levels of importance between medical
student roles on the core clerkship and sub-internship
overnight experiences. Analysis of the variance was used to
determine perceived importance of medical student roles by
respondents’ academic rank. SPSS, version 22 was used for
The response rate for the overnight experiences survey section
was 77.8 (n=94/121). By rank, 26 % of respondents were
Professors, 44.5 % were Associate Professors and 29.5 % were
Assistant Professors. Fifty-five percent were from private
medical schools and 45 % were from public medical schools.
Respondents were predominantly clerkship directors
(63.7 %); 2.1 % were sub-internship directors, 29.8 % were
both sub-internship and core clerkship directors and 6.4 % had
A minority of respondents (38.7 %) reported that students at
their institutions had overnight experiences during the
clerkship or sub-internship (40.2 % of respondents). On average,
students participated in 4.0±1.0 overnights on the clerkship
and 4.8±1.9 during the sub-internship. Only 5 % reported
students participating in dedicated night-float work outside
of the clerkship or sub-internship.
Among those respondents who reported student
participation in overnights during the clerkship or sub-internship,
a majority reported that students worked directly with
housestaff (92 and 95 %, respectively), admitted new
patients (95 and 100 %, respectively), and performed
subsequent day/follow-up visits (77 and 75 %, respectively).
Fewer respondents reported clerkship and sub-internship
students working directly with attending physicians (42
and 45 % respectively), or doing consecutive overnights
as a night-float responsibility within their medicine rotation
(42 and 38 % respectively). Sub-internships were more
likely to involve cross cover responsibilities than clerkships
(77 % vs. 62 %, p = 0.009).
Respondents rated the overall importance of overnight work
in the sub-internship higher than the clerkship (3.2±1.2 vs. 4.0
±1.1, p<0.001). Although not statistically significant, there
was a trend toward decreasing perceived overall importance
with increasing academic rank for both the clerkship and the
sub-internship. There was a difference in assistant and full
professors’ perceived importance of overnight work for
admitting new patients during the clerkship (4.4±0.8 vs. 3.3±
1.6, p = 0.01) and the sub-internship (4.7 ± 0.5 vs. 3.8 ± 1.3,
p=0.016). Additionally, there was a significant difference in
associate and full professors’ perceived importance of
overnight work for experiencing future roles during the clerkship
(4.0±0.9 vs. 3.3± 1.2, p=0.04) and sub-internship (4.6±0.6
vs. 4.1±0.7, p=0.037).
Respondents felt many aspects of overnight experiences
were important in the clerkship and/or the sub-internship,
and most activities were felt to be more important in the
subinternship. (Fig. 1) Respondents rated admitting new patients
(3.9±1.2(clerkship) and 4.2±1.1 (sub- internship), p<0.001),
following the course of new patients (4.1±0.9 and 4.4±0.8,
p< 0.001), and responding to patient emergencies (4.0±0.1
and 4.5± 0.8, p<0.001) as important aspects of the overnight
experience. Several other aspects of overnight work, such as
responding to cross cover issues (3.5 ± 1.2 vs. 4.4 ± 0.8,
p<0.001) and experiencing future roles as an intern (3.8±1.0
vs. 4.4±0.7, p<0.001), were also viewed as having greater
importance in the sub-internship than in the clerkship. For
both the clerkship and sub-internship, overnight work was
perceived as less important in allowing students to observe
future roles as an attending (2.6±1.3 and 2.9± 1.3, p<0.001
Repeated themes were collated within the free text response
section (Table 1). The most common reported reason to
support overnight work was the chance for learners to work up
Bfresh^ patients and follow the initial course of disease. The
ability to observe the role of the resident at night was also
considered an important benefit of overnight work. Untapped
learning experiences, the ability to work as part of the
nightfloat team, cross coverage opportunities and teaching proper
sign out techniques were less commonly identified as reasons
to include overnight experiences. The unique overnight work
environment with less competing responsibilities was
considered another advantage of overnight clinical work. The most
commonly reported negative themes or reasons not to support
overnight experiences were poor nighttime supervision of
students, medical student duty hour violations, challenging
logistics and educators who were commenting upon the old
Btraditional^ call schedule where students stayed in house for
24–36 h. The inconsistency of the learning environment
overnight, the inability to attend daytime didactics and the lack of
call room space were reported less frequently as barriers to
Positive and negative themes extracted from survey respondent comments about whether or not students should work overnight. The frequency with
which each theme was cited is listed in the column following the theme. Comments were optional to record and were not limited to a single theme
overnight call. Finally, multiple respondents questioned the
appropriateness of overnights for third years as opposed to
Our findings confirm the continuing trend of decreasing
student participation in overnight experiences in core Internal
Medicine rotations.2,6 The majority of respondents (61.3 %)
reported having no overnight experiences for clerkship
students or sub-interns (59.3 %).
The recently introduced Association of American Medical
College’s Core Entrustable Professional Activities for
Entering Residency (CEPAER) will likely increase focus on how
medical school curricula prepare students for residency.21
Literature about the transition from medical school to
residency highlights the value of students gradually gaining
proficiency in how to approach and manage clinical problems and
decision making.22 More opportunities for students to manage
patients and practice their upcoming roles as residents reflect
an important paradigm for future doctors’ training.18,22 Our
findings suggest that overnight experiences, once an integral
part of undergraduate and graduate medical training, may still
have a role in preparing medical students for their future
According to the survey results, overnight experiences were
a particularly important venue for admitting new patients.
While no precise national data exists on the timing of
admissions to internal medicine services, a large percentage (62 %)
of emergency room visits that might lead to admission occur
after Bnormal business hours.^23 Smaller studies have found
that a large percentage of patients are now being admitted by
night-float teams and handed off to day teams.9,10,24 In the
survey, most respondents whose students rotated on
overnights in the clerkship or sub-internship reported students
admitting patients during overnight experiences. Tasks related
to admitting and following the initial course of admitted
patients were also perceived as an important component of
overnights. Certainly students working during the day have
the opportunity to admit new patients who have not been
extensively worked up by others. However, our findings imply
that limited student participation in overnights may represent a
missed opportunity to give students greater exposure to
admitting the undifferentiated patient. Given that at least seven of
the Core Entrustable Professional Activities for Entering
Residency (CEPAERs) have skills that are well taught through the
admission of patients, the role of overnight experiences in
providing students with greater admitting opportunity is worth
further study. It will be important to determine if students who
work exclusively during the day admit enough new patients
and if the addition of overnight work increases this
The survey particularly highlights how overnights in
the sub-internship might prepare students for internship
and residency. Multiple aspects of overnight work were
viewed as more important for sub-interns than for
clerkship students. Responding to emergencies and
cross cover were noted skills felt to be particularly
relevant to internship. The opportunity to ease the
transition between student and intern likely was a
major contributor. Many survey respondents supported
overnights especially for sub-interns and commented
that overnight hospital experiences offered an
environment that fostered the gradual increase in responsibility
for the student. As the discussion of the particular
values of the fourth year of medical school continues,
the perception of the importance of overnights in the
sub-internship may be important to consider.
Overnights may be easier to incorporate into a fourth year
schedule that lacks the rigid time frame and didactic
schedule of the clerkship year.
Students on core internal medicine rotations,
according to respondents, rarely participate in night-float
rotations and the majority do not work consecutive
overnights. However, upon starting internship, graduating
students will almost certainly rotate extensively through
night-float services,8 where they will work multiple
consecutive overnights. The ACGME currently mandates
that all residents be taught to assess and be aware of
fatigue and assess their Bfitness for duty.^25 Learning to
adjust to a nocturnal schedule is a skill that might not
be easily or safely taught while concurrently providing
direct patient care as a resident. There may be value in
preparing students to recognize and cope with the
fatigue that comes with a nocturnal schedule during
medical school. The survey should prompt a discussion of
whether undergraduate medical educators might
incorporate overnights into their curricula in response to the
changes at the graduate medical education level, to
expose trainees to overnight work prior to internship.
While much has been written on the effects of fatigue
and a nocturnal schedule, little has been published on
how to teach students and residents to recognize and
cope with fatigue.
Despite the perceived potential benefits of overnight
experiences, respondents raised several concerns. These
included students missing daytime didactics, the limited
availability of call room space, the challenging logistics
to create student overnight schedules, the need to
maintain student duty hours and the lack of adequate
supervision for students overnight. These barriers suggest that
many survey respondents did not distinguish between
overnight experiences and traditional overnight call.
For example, limited availability of call room space is
immaterial if students are doing a night-float rotation
where they are expected to be working throughout the
night and sleeping during the day. It was interesting that
the most senior faculty members were most reticent to
support overnight experiences, while junior faculty
members were more likely to rate overnight experiences
as important. Perhaps this reflects that most of the
senior faculty participated in overnight call before duty
hour changes and considered the older schema of
traditional overnights rather than emerging night-float
structures. Regardless of the structure of overnight
experiences, it may be difficult to convince students of the
need to remain in the hospital overnight, as they are not
a part of the current overnight cul ture at most
There are several limitations to consider. The survey
only asked about perceived barriers to overnights in the
free text question. Generalizability to other disciplines is
limited, as the survey only assessed student involvement
in overnight work during the internal medicine clerkship
and sub-internship. Findings also represent clerkship
directors’ perception of student involvement in overnight
work; actual student participation was not measured.
Students’ perceptions of overnight work were also not
assessed. No data exists on students’ willingness to
remain in the hospital overnight, but it can likely be
assumed that the addition of more overnights would not
be widely welcomed. Most importantly, the survey did
not examine whether the perceived decrease in overnight
experiences has impacted students’ attainment of
milestones and core competencies. Lastly, the survey
included a small number of Canadian respondents who are not
affected by ACGME regulations.
The survey data suggest that the progressive
disappearance of overnight experience from the medicine
clerkship and sub-internship is a topic worth addressing.
While there may be challenges adding overnight
experiences or transitioning from traditional overnight call, it
is important to also consider what may be lost from
student training without overnight experience. It will
be important to consider how to compensate for the
decreased opportunity to admit and follow newly
admitted patients and cross cover, activities that may be less
prevalent with the loss of overnight rotations. Medical
student education is closely tied to and affected by
changes in graduate medical education. Duty hour
regulations have made major changes to resident schedules,
particularly around nights. Yet little data or discussion in
the undergraduate literature has focused on how to adapt
to these newest changes. This survey will hopefully
serve as a starting point for how overnights can remain
a key part of facilitating the transition of medical
students into residents.
Acknowledgements: The authors acknowledge Katherine Chretien,
MD for her contributions to the data collection. There was no funding
for this study
Conflict of Interest: The authors declare that they do not have a
conflict of interest.
Disclaimer: The views expressed in this manuscript are those of the
authors and do not necessarily reflect the official policy or position of
the Uniformed Services University of the Health Sciences, Department
of Defense, nor the U.S. Government.
Corresponding Author: Eric N. Goren, MD; Perelman School of
Medicine, University of Pennsylvania, 3400 Spruce St #2009,
Philadelphia, PA 19104, USA (e-mail: ).
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