“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.