“Who’s on Backup?”—Exploring Internal Medicine Residency Backup Coverage Systems: Findings from a National Survey

Background Little is known about backup coverage systems for clinical coverage when resident physicians call in for acute absences. Objective To define prevalence, core characteristics and explore challenges of backup coverage systems in Internal Medicine (IM) residency programs. Design A nationally representative, cross-sectional survey of US IM program directors (PDs) explored “backup” coverage systems. Participants PDs of 466 IM residency programs accredited by the Accreditation Council for Graduate Medical Education responded during August–December 2023. Main Measures Responses were analyzed using inferential statistics and thematic analysis of an open-ended question. Key Results Response rate was 57.1% (266 of 466). IM programs reported formal (92.9%, 247/266) or informal (6.4%, 17/266) backup systems. Most (64.3%, 169/263) felt use of the backup system had increased since the COVID-19 pandemic. Over 90% of programs listed acute illness, family emergencies, fatigue/impairment, and bereavement as reasons for backup coverage. Most programs (> 90%) provided coverage for absences from the inpatient ward, ICU services, and/or night float; however, 40.2% covered absences in primary care clinics. Most programs (87.4%, 229/262) had residents on backup during other clinical/educational rotations. Fewer than 20% of programs compensated residents for backup, namely time off and decreased likelihood of pull for future coverage. Only 15.4% (8/52) of programs provided monetary compensation. For long-term absences, 82.7% (220/266) of programs coordinated trades and 35.7% (99/266) used backup. Six themes characterized challenges of backup coverage: healthcare resources, call-ins culture change, balancing equity, patient care versus education, administrative burden, wellness/ burnout focus, parental/extended leave requirements. IM PDs expressed competing demands with backup systems. Conclusions While backup systems are nearly ubiquitous in IM residency programs, PDs report significant strains in these systems including possible cultural shift in illness definition, workload imbalances post-COVID, and prioritization of inpatient coverage over primary care. System-level changes are needed to improve backup coverage systems.