Association Between Hand-off Patients and Subject Exam Performance in Medicine Clerkship Students

BACKGROUND: Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students. OBJECTIVE: To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance. DESIGN: Observational study over 1 year. PARTICIPANTS: Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems. MEASUREMENTS: Primary outcome: Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores. MAIN RESULTS: Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B=0.26, P<0.001) and the number of full evaluations completed on fresh patients (B=0.20, P=0.048; model r(2)=0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B=0.22, P=0.002; r(2)=0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B=0.27, P=0.03; r(2)=0.34). CONCLUSIONS: Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.