Lost in transition: the experience and impact of frequent changes in the inpatient learning environment

The traditional "rotating" model of inpatient training remains the gold standard of residency, moving residents through different systems every two to four weeks. The authors studied the experience and impact of frequent transitions on residents. This was a qualitative study. Ninety-seven individuals participated in 12 focus groups at three academic medical centers purposefully chosen to represent a range of geographic locations and structural characteristics. Four groups were held at each site: residents only, faculty only, nurses and ancillary staff only, and a mixed group. Grounded theory was used to analyze data. Perceived benefits of transitions included the ability to adapt to new environments and practice styles, improved organization and triage skills, increased comfort with stressful situations, and flexibility. Residents primarily relied on each other to cope with and prepare for transitions, with little support from the program or faculty level. Several potentially problematic workarounds were described within the context of transitions, including shortened progress notes, avoiding pages, hiding information, and sidestepping critical situations. Nearly all residents acknowledged that frequent transitions contributed to a lack of ownership and other potentially harmful effects for patient care. These findings challenge the value of the traditional "rotating" model in residency. As residents adapt to frequent transitioning, they implicitly learn to value flexibility and efficiency over relationship building and deep system knowledge. These findings raise significant implications for professional development and patient care and highlight an important element of the hidden curriculum embedded within the current training model.