Using Team Census Caps to Optimize Education, Patient Care, and Wellness: A Survey of Internal Medicine Residency Program Directors

Purpose To discover whether internal medicine (IM) residency program directors use lower-than-required caps on general medicine wards, critical care units, and inpatient subspecialty wards; describe justifications for lower-than-required general medicine ward caps and strategies for when caps have been exceeded or the number of patients is a detriment to critical thinking or education; and assess whether caps were associated with program characteristics. Method From August to December 2016, the Association of Program Directors in Internal Medicine surveyed all member program directors about team caps and their effects on the learning environment. Responses were appended with publicly available or licensed third-party data. Programs were categorized by type, size, and region. Results Overall response rate was 65.7% (251/382 programs). Nearly all (244/248; 98.4%) reported caps for general medicine ward teams (mean = 17.0 [standard deviation (SD) = 4.2]). Fewer (171/247; 69.2%) had caps for critical care teams (mean = 13.8 [SD = 5.4]). Fewer still (131/225; 58.2%) had caps for inpatient subspecialty ward teams (mean = 14.8 [SD = 6.0]). Fewer first-quartile programs (0-28 residents) reported having caps on inpatient subspecialty teams (P < .001). Directors reported higher caps compromised education (109/130; 83.8%), patient care (89/130; 68.5%), and/or resident wellness (77/130; 59.2%). Nonteaching services (181/249; 72.7%), patient transfers (110/249; 44.2%), or "backup" residents (67/249; 26.9%) were used when caps are reached or the number of patients is detrimental to critical thinking or education. Conclusions IM program directors frequently exercise discretion when setting caps. Accrediting bodies should explicitly encourage such adjustments and allow differentiation by setting.