Introduction

End-of-residency handoffs of residents' continuity clinic patients have been identified as an unaddressed patient safety concern.1,2 In 2011, an estimated 15 300 internal medicine, pediatrics, family medicine, psychiatry, and internal medicine–pediatrics (Med-Peds) residents finished residency3 and turned over the care of their ambulatory continuity clinic patients to another resident, accounting for an estimated 1 million patient transfers of care in the United States.

During the handoffs of their ambulatory patients, residents need to convey concerns about social and family issues, and longer-term follow-up management of health concerns, in addition to the standard content of handoffs. These handoffs often are made from more experienced senior residents to a less experienced junior resident and there may be a significant time lag between the handoff and the patient's next visit to the clinic. In addition, between 19% and 46% of internal medicine clinic patients identified as high risk also failed to follow up with a provider within a reasonable time frame.4,5

Handoff training is a component of the Accreditation Council for Graduate Medical Education requirements,6 yet consensus for best practice recommendations has not been reached for assessing or training residents in end-of-residency clinic handoffs. Studies of efforts to improve the end-of residency handoff have focused on advance notice of the change in provider,7,8 improving patient follow-up and outcomes through multifaceted approaches,5,9 and recording of handoff information in the electronic health record (EHR).10 Recent best practice suggestions include formally orienting the patient to the handoff process, standardizing data entry, prioritizing scheduling, and conducting face-to-face oral handoffs.2,5,9

Our pilot work identified 3 key features of handoffs to consider in developing best practices: (1) introduce residents to a formal handoff system, (2) set expectations for performing handoffs, and (3) provide residents with protected time to perform end-of-residency handoffs.10

We created a survey to assess the characteristics of end-of-residency handoffs in Med-Peds programs, including the 3 attributes of effective handoffs identified through our pilot. Med-Peds programs are a good target for this type of study because of their focus on primary care, their connection to categorical medicine and pediatrics programs, and because the fourth year of residency in the specialty lends itself to a longer resident-patient continuity relationship. Med-Peds programs exist in community and academic centers, and in 2011, 41% of categorical pediatrics programs and 20% of internal medicine programs had an attached Med-Peds program.11

Methods

Results

Handoff System Characteristics

We analyzed the 30 programs that provided complete responses to the questions on characteristics (table).

table Features of Handoff Systems

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Of the 6 programs that reported offering protected time for end-of-residency handoffs, 3 provided 4 hours, 2 programs allowed 2 full clinic sessions, and 1 program did not identify how many protected hours were allocated. In response to the question about how end-of-residency handoffs were conducted, almost half of programs (14 of 30, 47%) indicated that a variety of communication methods were used. Inclusion of handoff information in the EHR was the most commonly identified medium (17 of 30, 57%), followed by oral handoffs (15 of 30, 50%). Common methods for end-of-residency handoffs are presented in the figure.

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Twenty-eight respondents answered an open-ended question about the characteristics of their end-of-residency handoffs. One of these programs had not reported use of a formal system for this type of handoff. Respondents from 13 of the 28 programs indicated that graduating residents self-identify patients with complex conditions. However, methods to deal with these patients varied among programs. Approaches to distributing these patients ranged from a lower-level resident accepting all patients of a graduating resident to a “conscription” process in which graduating residents' cases were distributed according to patient complexity and the accepting residents' level. In programs in which graduating residents did not identify patients with complex conditions, respondents reported that faculty decided the allocation of residents' patients. Two programs stated they attempt to balance the caseload of residents receiving these handoffs, and 7 respondents indicated that the new provider receives a face-to-face introduction to the patient before the change in provider.

Discussion

This is the first study to assess the use and characteristics of end-of-residency handoff systems for the ambulatory patient of graduating residents. Fewer than half of the Med-Peds residency programs responding to our survey reported having an outpatient handoff system, and the characteristics of those systems are highly variable. Institutional culture appears to play a role, since programs were more likely to have a system in place if their parent categorical programs had one, although only 12% of institutions had handoff systems in all 3 programs (categorical internal medicine, pediatrics, and Med-Peds).

Our results have several implications. High-risk patients often do not receive any follow-up with their newly assigned providers (66%–91% in the studies of Pincavage et al5 and also of M.J.D, J.M.C., R.E.T., unpublished data, July 2012) or within a reasonable time frame.4,5 In many programs there is an absence of efforts to balance the distribution of patients who have complex conditions to their new resident providers, which makes it difficult to rebalance caseloads, a method used in ambulatory psychiatry.16 Recording end-of-residency handoff information in the EHR has the advantage that all the handoff information is retained until the patient presents for follow-up, and that the information is accessible to all providers. Although oral handoffs were the second most commonly reported approach, information transferred in this fashion may be lost unless the patient follows up with the identified provider in a reasonable time frame. Thus, if residency programs initiate efforts to focus on just 1 formal aspect of the outpatient handoff, emphasizing the importance of using EHR might have the biggest impact.

Our study has several limitations. First, our survey was not validated. Second, Med-Peds programs are small, and findings may not be generalizable to other programs. Some programs are also dependent on their parent categorical programs, particularly if their continuity clinic is not a dedicated Med-Peds clinic. Third, underreporting error could have occurred if program directors were not aware of handoff processes, and they may not have had as much authority to make changes regarding outpatient handoffs. Fourth, nonresponse bias could have affected our survey response rate. We also did not define key terms such as system, formal introduction, and other key descriptors that could have strengthened our ability to draw firmer and more generalizable conclusions. Finally, our study did not examine the role of continuity of attending physicians. It is possible that outpatient handoffs are viewed as less critical from a patient safety point of view and there may be less of a focus on continuity of care at the attending level.

Conclusion

While fewer than half of responding Med-Peds programs have outpatient handoff systems in place, incorporation of formal end-of-residency handoffs in residency training, and offering protected time for these handoffs, puts an emphasis on the handoff as a formal part of physicians' work and reinforces the importance of communication. Inclusion of end-of-residency handoff information in the EHR, where is it retained until the patient's next visit and visible to all providers, may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

Future studies should focus on achieving added consensus on best practices for resident training in outpatient handoffs, as well as formal efforts at evaluating handoff quality, and the effect of these handoffs on patient outcomes.