We developed a brief, formal curriculum to teach sign-out skills to interns that incorporated a variety of instructional strategies, including discussion, modeling, individual practice, evaluation, and feedback. Overall satisfaction with the course was high and participants reported improved comfort with sign-out skills at the conclusion of the workshop.
The most common suggestion for improving the curriculum was to offer it even earlier in the academic year. One alternative would be to present the curriculum at the June intern orientation. However, this would make real-time practice with actual patients impossible. In addition, interns who have not yet done any night-time cross-coverage might have less appreciation for the types of problems commonly encountered overnight that can be avoided with good sign-out. In fact, we found that interns had difficulty with the anticipatory guidance part of sign-out, although they had already had some experience on the wards.
We have several plans for further expansion and evaluation of the curriculum. We are now developing a sign-out evaluation tool so that residents can provide evaluation and feedback for their interns throughout the year. This tool will include areas of deficiency noted during the small group sessions, such as structured format, anticipatory guidance, and read-back. In addition, we plan to repeat our direct observation of house staff sign-outs to determine the curriculum’s effect on actual sign-out practices. Because of the inherent steep learning curve of the intern year, we cannot compare practices before and after the curriculum in the intervention group itself. Rather, we will observe practices in the intervention group in the spring and compare them to those of a previous cohort of interns who did not receive any sign-out education or evaluation. Finally, based on feedback from medical student participants, we are exploring the possibility of developing a similar curriculum for the medical school.
In the next iteration, we will also address two challenges that we encountered during the first implementation. First, several participants were on outpatient or elective rotations and were disappointed not to have the opportunity to practice giving sign-out. We have developed written sign-outs for use by participants who do not have their own patients so that all attendees can participate in the small group session. Second, despite presenting the curriculum at each of the hospitals through which our house staff rotate, we only reached approximately a quarter of all interns because those who were post-call or on vacation or elective and intensive care rotations were not available, and the new ward interns had difficulty making time to attend educational conferences. Next time, therefore, we will offer the workshop at each participating hospital during two different rotations.
In summary, we developed a formal sign-out skills curriculum incorporating a variety of teaching techniques; a novel structured sign-out format; and real-time practice, evaluation, and feedback for all participants. We intend this to be one step in improving residents’ communication competence and reducing medical errors from poor sign-out.