{"paper_id":"20aad16b-6ae6-46df-9cbc-3f6c38526268","body_text":"Effect of 24/7 attending coverage in the Neonatal Intensive Care Unit on fellow education. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Effect of 24/7 attending coverage in the Neonatal Intensive Care Unit on fellow education. Mitali Sahni, Anja Mowes This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.13983/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2020 Read the published version in BMC Medical Education → Version 4 posted 4 You are reading this latest preprint version Show more versions Abstract Background There is a current change in type of attending coverage in the Neonatal Intensive Care Unit (NICU) from home calls to 24/7 in House. Effects of this increased attending physician presence on education of NICU fellows has not been studied. The objective of this study is to evaluate the fellows’ perception of in house attending coverage on their education and evaluate its effect on their perceived autonomy. Methods A secure, anonymous, web-based survey was designed using RedCap. The web-based survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training & Early Career Neonatologists. Questions were focused on perception of IH attending coverage on fellows’ educational experience including the respondent’s perceived ability to make independent decisions (autonomy). Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small. Results One hundred and twenty-three surveys were analyzed, that included responses from 82 fellows & 41 early career neonatologists. 52% reported having 24/7 attending in-house (IH) coverage. 30 of the 123 respondents experienced a change in model of attending coverage during their training. Among these 30, only 26.6% preferred the model of attending IH coverage. The respondents currently working in IH models, when compared to those in non-IH coverage models felt IH attending coverage was beneficial for fellow education (p <0.05) but was less likely to give fellows autonomy for decision making (p=0.02). Conclusion In our survey respondents with in house attending, had a more favorable view of its benefit on fellow education. Institutions practicing or considering IH attending coverage should consider use of adequate measures to balance fellow supervision and education. Educational Philosophy and Theory Internal Medicine Education Supervision Autonomy Neonatology House staff Survey Figures Figure 1 Background There is a current change in type of attending coverage in the neonatal intensive care units (NICU) across the United States where more programs are transitioning from home coverage to 24/7 in house (IH) attending coverage. In the era of increased duty hour restrictions for house staff and stronger recommendations for their supervision by Accreditation Council for Graduate Medical Education (ACGME), the attending presence in the intensive care units (ICU) has increased(1). At our institution we transitioned to attending in house coverage in July 2017. This change in practice has been attributed to various reasons including but not limited to improved patient outcomes, presence of additional help during emergent situations and improvement in practice(2). However, the data available does not clearly support this thought and is, at best, ambivalent.(3-5) Some have argued that changing to an IH model will affect the fellows’ education in a negative way by decreasing their autonomy to make decisions(6). Experts fear that in this model, fellows tend to defer to attending physicians to make decisions, instead of making and defending their own decisions.(6) This practice may also lead to younger attending physicians being less comfortable with allowing physicians in training to make clinical decisions on their own.(6) During a recent study done to evaluate the perception of 24/7 intensivist presence in the Pediatric Intensive Care Unit (PICU) on house staff education – a large number of respondents felt that the house staff was not prepared for independent practice after training in a IH attending coverage model.(7) Concerns about fellows’ autonomy were also raised in a study done to evaluate their education in Pediatric Cardiac Intensive Care unit.(8) Effects of increased attending physician presence on education of NICU fellows have not been studied. We hypothesized that 24/7 intensivists’ coverage in the NICU at academic institutions would cause a perception of decreased autonomy and would not be perceived as being beneficial for their education. Methods We designed an anonymous web-based survey of 13 questions and distributed the survey by using the secure RedCAP database. This survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training & Early Career Neonatologists (TECaN) targeting the current fellows and recently graduated attendings that were part of the TECaN list serve. Questions in the survey were created by the study team based on their experience in NICU and with fellow education. Questions were focused on perception of IH attending coverage on fellows’ educational experience. The initial survey instrument was tested by a few fellows and early career neonatologists at the author’s parent institution and was revised based on their feedback. The results from this initial testing were not included in the survey results of the study. IH coverage was defined as the presence of a neonatology attending in the hospital 24 hours per day, 7 days a week, whereas home coverage (HC) was defined as neonatology attending taking calls from outside the hospital during nontraditional hours (nights and weekends). There were also some mixed coverage models reported where the attending stayed in house with new trainees or under discretionary circumstances. We used a 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) to assess subjective questions regarding the respondents’ perception of the effect of attending presence in the NICU. To facilitate the assessment of the respondent’s perception, we grouped the strongly disagree and disagree as one group - \"disagree\" and similarly combined together strongly agree and agree as - \"agree\" while neutral formed the third group. A copy of the survey instrument used has been provided as supplement 1. We compared the difference in perception between respondents in IH attending model versus (vs.) respondents from HC and mixed models. There was no specific definition used for “autonomy” in the study, since we evaluated the “perceived autonomy” by fellows and would be determined by the respondent’s perception and not by the investigator. Our sample size was determined by the number of responses and not by a power analysis. Given 64 IH and 59 non-IH respondents, doing a chi-square test on a yes/no outcome (such as agree/strongly agree versus all other responses), we would have 80% power, two-tailed, for a difference on the order of 50% versus 25% agree/strongly agree between the two groups. Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small. P values <0.05 were considered significant. The institutional review board at Drexel University approved this study with a waiver of consent. Results The survey was sent to 1041 subjects that were part of the TECaN list serve. However, not all members were eligible to take the survey, since some early career neonatologists had completed training more than 5 years ago. We report the results from 123 completed surveys that include responses from 82 fellows & 41 early career neonatologists that graduated within the past 5 years. 52% trained in NICUs with IH attending coverage. 36% trained in institutions with attending HC model and 12% were from a mixed model where the attending stayed in house in certain situations. Most participants perceived the effect of IH attending coverage on patient care to be beneficial (Fig 1). However, when asked if the presence of attending in the NICU improved the fellow’s education the responses divided almost equally between agree, neutral, and disagree (Fig1). More people in the IH attending model than the HC and Mixed Model (54.6% versus 15.2%) felt that having attending in house was beneficial for their education, p < 0.05. The majority of respondents felt they had autonomy in their NICU (Fig1). However, more respondents in a model with IH attending disagreed with having autonomy, than those in HC and Mixed Model (10.9% versus 5%), p = 0.02. Interestingly, 30 of the 123 respondents experienced a change in model of attending coverage during their fellowship training. Among these 30 respondents, only 28% preferred having the model of attending IH coverage, while 14% commented on the benefits of both models. For instance, one subject responded that his/her preference, “depended on the hospital- in an ECMO center, preferred in house attending call, while in a 70 bed Level III, preferred attending to be at home.” The ACGME encourages programs to have a checklist that provides fellows with guidelines to suggest - when to call attending with situations/patient status changes(9). Only 30.9% of the respondents acknowledged having such a checklist. Most respondents perceived the reason for the increased attending presence to be better patient safety and having more help in emergent situations. Our survey participants acknowledged that programs with attending IH took certain measures to promote fellows’ autonomy that have been listed in Table 1. When asked about the factors that most influenced the fellows’ autonomy, our participants perceived them to be attendings’ preferences and fellows’ experience. Another respondent expressed that the autonomy was also affected by the division practices. For example, the respondent noted that, “During residency their second-year resident supervised interns at meconium exposed deliveries. While as a fellow, they have an intern, resident, fellow and sometimes attending present at the delivery.” In their opinion, “It does not allow for autonomy and limits education. I feel it can be harmful after graduation when there is no longer someone physically present that is supervising you.” Table 1: Fellows’ perception of IH attending coverage model Question Most frequent answers (number of respondents that chose the listed reason – could choose multiple reasons) Most important reason for switching to IH model -Patient safety (37/123, 30.1%) -Possible emergency situation that requires additional help (37/123, 30.1%) In IH model, how does the program encourage fellow’s autonomy -Fellows encouraged to act independently/make a plan prior to consulting attending (79/123, 64.2%) -Nurses encouraged to call fellow first (68/123, 55.3%) Factor influencing fellow’s autonomy for decision making - Attending's preference (103/123, 83.7%) - Fellow's experience (98/123, 79.7%) - Patient pathology (87/123, 70.7%) - Attending’s age (49/123, 39.8%) Discussion There has been an ongoing debate about the effect of 24/7 intensivist coverage in critical care units in both adult and pediatric hospitals.(10) Numerous studies have been done in the PICU and pediatric cardiac ICUs to evaluate the effect of this on patient outcomes and house staff education.(7, 11) However there is a paucity of such investigations in the NICU and the published data is not very reliable. In our study we received responses from 123 fellows and early career neonatologist from 1041 subjects. Since some early career neonatologists had completed training more than 5 years ago, they were not eligible to take the survey and hence, our response rate of 11.8% is not accurate. We chose to compare the results of the IH group with the non-IH group, in which we combined the responses from HC and mixed model groups. Since, the mixed models were primarily home coverage and only did IH coverage in specific situations, we believe these groups were better placed together. This also allowed us to better perceive the opinion about IH coverage from respondents that only worked in that model vs. those that did not. The results from our survey suggest that most respondents perceive that concerns about patient care and safety have led to an increase in IH coverage. There are conflicting feelings regarding the benefits of IH coverage on fellow education, however more participants in the IH coverage model perceived it to be better for fellow education than participants in non-IH models. In a previous study done to evaluate patient volume, staffing and workload in relation to risk adjusted outcomes; the UK Neonatal Staffing Study Group reported less nosocomial infections and quantitatively less death or brain damage with less neonatal consultant coverage.(5) In this study, the authors defined neonatal consultant coverage as pediatricians with more than 50% of their clinical sessions committed to neonatal care. In another study done in Canadian NICUs the investigators showed that units with in-house faculty or fellow coverage had lower nocturnal mortality rates relative to units with coverage by residents or other personnel.(12) Despite this unclear data, there is a vast majority of academic centers with fellows in training that are adapting the IH attending coverage model. In a large observational study done using a virtual Pediatrics System Database, Gupta et al demonstrated that 24/7 IH attending coverage in the PICU is associated with improved overall patient care and survival after cardiac arrest compared with ICU’s with HC model.(4) In a national survey of pediatric intensivists, pediatric critical care fellows and residents evaluating the perception of 24/7 IH attending on house staff education, only 50% of intensivists and 67% of house staff felt that house staff was well prepared for independent practice after training in an IH model of attending coverage. In this survey respondents currently working in IH models had a more favorable perceptions of the effects of IH coverage on house staff autonomy (P < .0001), supervision (P < .0001), and preparation for independent practice (P < .0001) when compared with those training in HC models.(7) Similarly, in our survey respondents at institutions with IH coverage felt strongly that IH coverage was beneficial for fellows’ education when compared to respondents from institutions with HC and mixed model. This may be due to the respondent’s familiarity with their model or that centers with IH model may have found ways to adapt to this changed model of attending coverage and utilize attending presence for improving the fellows educational experience. This may also suggest that there is a biased perception amongst respondents from institutions with HC model about the deleterious effects of IH coverage on fellows’ education. The current guidelines of increased supervision requirement by ACGME (13) and recommendation of the society of Critical Care Medicine to have an intensivist led care of patients in the ICU have led to more institutes moving towards increased attending in house presence.(14) This increased attending presence in the NICU could provide an opportunity to improve fellows’ education. Another suggestion would be to encourage fellows to have a plan of action ready prior to consulting attendings and attendings could utilize this opportunity to convert the bedside clinical situation into a teachable moment. There is a delicate balance between supervision and autonomy. In our survey, only 10 respondents felt that they did not have autonomy in their NICU. The fellows that felt lack of autonomy in their NICU were more likely to be training in centers with IH attending coverage. 83.7% of our respondents noted attending preference and 39.8% noted attending’s age as factors influencing the level of autonomy, they get in their NICU. In a commentary about increased attending presence in the NICU, Jobe and Martin remarked, “Younger attending physicians may be less comfortable in allowing physicians-in-training to make decisions, manage patients, and develop independence. Residents then become scribes for the clinical team rather than active participants, and fellows defer to attending physicians rather than making and defending decisions.”(6) Fellowship programs have come up with different strategies to help provide fellows autonomy in the presence of IH attending. The most frequent strategies on how their program promoted fellows autonomy, involved: encouraging nurses to call the fellows first and encouraging fellows to make their own plan before calling the attending. Another suggestion could be for the attending to not be physically present in the unit during call. This would decrease the chances of the nurses approaching the attending with concerns directly and allowing them to be available promptly when the fellow needs help. In interest of patient safety, the ACGME recommends that fellowship program should have a checklist that provides fellows with guidelines for circumstances and events in which fellows must communicate with their supervising faculty(9). Only 30.9% of our respondents acknowledged having such a checklist. A better use of this tool may also help with addressing the issue of patient safety and balancing autonomy. Although our study provides interesting and enlightening data, it is limited by the survey design and route of distribution. Since the TECaN list serve does not have a separate list for current fellows and early career neonatologists, we are unable to provide a response rate for current fellows who took this survey. Another limitation is the low response rate of the survey and may affect the validity of the results. The study also suffers from reporting bias since it is a self-reported survey and our ability to interpret the data. In addition this study only provides data about the perception of the respondents to change in attending coverage model. It does not objectively determine its effect on fellow competence, patient care and patient outcomes. However, it helps identify the major areas of concern with the perception of IH attending coverage in the NICU and can help guide programs to better address these concerns and implement measures to improve fellows’ educational experience. Based on the results from this survey a qualitative follow up study could be done, focusing on the fellows in HC model and analyze why they feel that attending presence would not be beneficial. Conclusion Concern for patient care and safety have appropriately led to increased attending presence in the NICU. However, its impact on fellow education and autonomy are important considerations that have not been well studied. Our survey indicates that there are conflicting feelings regarding its benefit on training of neonatal fellows, however fellows training in IH model find it to be beneficial for their education. The centers undergoing this transformation should consider taking adequate measures to balance patient safety and fellow’s autonomy as well as utilize the increased attending presence as a tool to improve fellows’ educational experience. List Of Abbreviations NICU: Neonatal Intensive Care Unit; IH: in house; ACGME: Accreditation Council for Graduate Medical Education; ICU: intensive care units; PICU: Pediatric Intensive Care Unit; TECaN: Training & Early Career Neonatologists; HC: home coverage; Declarations Ethics approval and consent to participate The Institutional Review Board (IRB) at Drexel University, Philadelphia, PA approved the study. The need for written consent was waived by the IRB. Consent for publication Not applicable Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding No external funding Authors' contributions MS conceptualized and designed the study, collected the data, carried out the statistical analysis and drafted the initial manuscript. AM conceptualized and designed the study, coordinated and supervised data collection, reviewed and revised the manuscript, and approved the final manuscript as submitted. Acknowledgements We thank Dr. Ed J. Gracely, PhD, for his assistance and guidance with the statistical analyses. References Mercurio MR, Peterec SM. Attending physician work hours: ethical considerations and the last doctor standing. Pediatrics. 2009;124(2):758-62. Burnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. American journal of respiratory and critical care medicine. 2010;181(11):1159-60. Iannucci GJ, Oster ME, Chanani NK, Gillespie SE, McCracken CE, Kanter KR, et al. The relationship between in-house attending coverage and nighttime extubation following congenital heart surgery*. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2014;15(3):258-63. Gupta P, Rettiganti M, Rice TB, Wetzel RC. Impact of 24/7 In-Hospital Intensivist Coverage on Outcomes in Pediatric Intensive Care. A Multicenter Study. American journal of respiratory and critical care medicine. 2016;194(12):1506-13. Tucker J. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet (London, England). 2002;359(9301):99-107. Jobe AH, Martin RJ. 24/7 neonatal intensive care unit attending physician coverage: a clash of missions. American journal of respiratory and critical care medicine. 2010;182(6):729-31. Rehder KJ, Cheifetz IM, Willson DF, Turner DA. Perceptions of 24/7 in-hospital intensivist coverage on pediatric housestaff education. Pediatrics. 2014;133(1):88-95. Owens ST, Owens GE, Rajput SH, Charpie JR, Kidwell KM, Mullan PB. Perceptions of 24/7 In-house Attending Coverage on Fellow Education and Autonomy in a Pediatric Cardiothoracic Intensive Care Unit. Congenital heart disease. 2015;10(3):E107-12. ACGME speciality specific program requirements (Neonatal-Perinatal medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/329_NeonatalPerinatalMedicine_2019_TCC.pdf?ver=-02-19-133646-910 . Arabi Y. Pro/Con debate: Should 24/7 in-house intensivist coverage be implemented? Critical Care. 2008;12(3):216-. Alfares FA, Jones MB, Ramakrishnan K, Endicott KM, Zurakowski D, Shankar V, et al. Perceptions of Bedside Cardiac Critical Care Registered Nurses on 24 Hour Attending Intensivist Coverage. Congenital heart disease. 2016;11(4):354-8. Lee SK, Lee DS, Andrews WL, Baboolal R, Pendray M, Stewart S. Higher mortality rates among inborn infants admitted to neonatal intensive care units at night. J Pediatr. 2003;143(5):592-7. Accreditation Council on Graduate Medical Education.Common Program Requirements. Available at:. https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements . Haupt MT, Bekes CE, Brilli RJ, Carl LC, Gray AW, Jastremski MS, et al. Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Critical care medicine. 2003;31(11):2677-83. Supplementary Files SurveyinstrumentEffectOf247AttendingCoverageIn.pdf Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2020 Read the published version in BMC Medical Education → Version 4 posted Editorial decision: Accept 08 Nov, 2020 Editor assigned by journal 04 Nov, 2020 Submission checks completed at journal 04 Nov, 2020 Editor invited by journal 04 Nov, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4683\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research article\",\"associatedPublications\":[],\"authors\":[{\"id\":4432970,\"identity\":\"98e93220-8afa-48eb-ae75-b86101d9fbee\",\"order_by\":0,\"name\":\"Mitali Sahni\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYDACZiB+YCAhxw/iJBQQpQWoJ8HAwliyAaTFgFhrEhgqEjccAHGI0aLbzn/wQ0KBBOPm86sTPzwwYJDnFzuAX4vZYWZmiQQDCWazG283AxkMhjNnJxDUwgDSwmZ24+wGkJYEg9uEtTD/AGrhMZ5xdvMPYrWwgWyRMODv3Ua0LWYWQC0GEjd4t4EYRPjl/MHHNz78qavv7z+7+eaPCht5fmkCWhBAAqxSgljlIMB/gBTVo2AUjIJRMJIAAHwGQAKiBEY8AAAAAElFTkSuQmCC\",\"orcid\":\"https://orcid.org/0000-0001-8145-2073\",\"institution\":\"Sunrise Children's Hospital\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mitali\",\"middleName\":\"\",\"lastName\":\"Sahni\",\"suffix\":\"\"},{\"id\":4432971,\"identity\":\"c4e69fc3-101c-4f24-8aba-235edfdeaa34\",\"order_by\":1,\"name\":\"Anja Mowes\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Drexel University College of Medicine\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anja\",\"middleName\":\"\",\"lastName\":\"Mowes\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2019-09-02 13:25:14\",\"currentVersionCode\":4,\"declarations\":\"\",\"doi\":\"10.21203/rs.2.13983/v4\",\"doiUrl\":\"https://doi.org/10.21203/rs.2.13983/v4\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12909-020-02372-2\",\"type\":\"published\",\"date\":\"2020-11-18T15:00:51+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":3512849,\"identity\":\"3474fb82-6f2b-4b75-b556-2a37f92246ad\",\"added_by\":\"auto\",\"created_at\":\"2020-11-11 15:16:09\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":73881,\"visible\":true,\"origin\":\"\",\"legend\":\"Fellows perception of in house attending coverage. \",\"description\":\"\",\"filename\":\"Figure1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4683/v4/d3497e478118116e4ade13a9.jpg\"},{\"id\":13614191,\"identity\":\"753de541-cce4-44a3-a49b-1ae2c6dff005\",\"added_by\":\"auto\",\"created_at\":\"2021-09-17 06:40:02\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":261872,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4683/v4/e195b49a-2efd-473e-8c0a-73ed46817062.pdf\"},{\"id\":3512848,\"identity\":\"c897dccc-d76b-4453-9b7b-fc837f10c38f\",\"added_by\":\"auto\",\"created_at\":\"2020-11-11 15:16:09\",\"extension\":\"pdf\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":40407,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SurveyinstrumentEffectOf247AttendingCoverageIn.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4683/v4/30b5f273e688f29e1d72c59d.pdf\"}],\"financialInterests\":\"\",\"formattedTitle\":\"Effect of 24/7 attending coverage in the Neonatal Intensive Care Unit on fellow education.\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eThere is a current change in type of attending coverage in the neonatal intensive care units (NICU) across the United States where more programs are transitioning from home coverage to 24/7 in house (IH) attending coverage. \\u0026nbsp;In the era of increased duty hour restrictions for house staff and stronger recommendations for their supervision by Accreditation Council for Graduate Medical Education (ACGME), the attending presence in the intensive care units (ICU) has increased(1). At our institution we transitioned to attending in house coverage in July 2017. This change in practice has been attributed to various reasons including but not limited to improved patient outcomes, presence of additional help during emergent situations and improvement in practice(2). However, the data available does not clearly support this thought and is, at best, ambivalent.(3-5)\\u003c/p\\u003e\\n\\u003cp\\u003eSome have argued that changing to an IH model will affect the fellows\\u0026rsquo; education in a negative way by decreasing their autonomy to make decisions(6). Experts fear that in this model, fellows tend to defer to attending physicians to make decisions, instead of making and defending their own decisions.(6) This practice may also lead to younger attending physicians being less comfortable with allowing physicians in training to make clinical decisions on their own.(6) During a recent study done to evaluate the perception of 24/7 intensivist presence in the Pediatric Intensive Care Unit (PICU) on house staff education \\u0026ndash; a large number of respondents felt that the house staff was not prepared for independent practice after training in a IH attending coverage model.(7) Concerns about fellows\\u0026rsquo; autonomy were also raised in a study done to evaluate their education in Pediatric Cardiac Intensive Care unit.(8) Effects of increased attending physician presence on education of NICU fellows have not been studied. We hypothesized that 24/7 intensivists\\u0026rsquo; coverage in the NICU at academic institutions would cause a perception of decreased autonomy and would not be perceived as being beneficial for their education.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eWe designed an anonymous web-based survey of 13 questions and distributed the survey by using the secure RedCAP database. \\u0026nbsp;This survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training \\u0026amp; Early Career Neonatologists (TECaN) targeting the current fellows and recently graduated attendings that were part of the TECaN list serve. Questions in the survey were created by the study team based on their experience in NICU and with fellow education. \\u0026nbsp;Questions were focused on perception of IH attending coverage on fellows\\u0026rsquo; educational experience. The initial survey instrument was tested by a few fellows and early career neonatologists at the author\\u0026rsquo;s parent institution and was revised based on their feedback. The results from this initial testing were not included in the survey results of the study.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIH coverage was defined as the presence of a neonatology attending in the hospital 24 hours per day, 7 days a week, whereas home coverage (HC) was defined as neonatology attending taking calls from outside the hospital during nontraditional hours (nights and weekends). There were also some mixed coverage models reported where the attending stayed in house with new trainees or under discretionary circumstances. We used a 5-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) to assess subjective questions regarding the respondents\\u0026rsquo; perception of the effect of attending presence in the NICU. To facilitate the assessment of the respondent\\u0026rsquo;s perception, we grouped the strongly disagree and disagree as one group - \\u0026quot;disagree\\u0026quot; and similarly combined together strongly agree and agree as - \\u0026quot;agree\\u0026quot; while neutral formed the third group. A copy of the survey instrument used has been provided as supplement 1.\\u003c/p\\u003e\\n\\u003cp\\u003eWe compared the difference in perception between respondents in IH attending model versus (vs.) respondents from HC and mixed models. \\u0026nbsp;There was no specific definition used for \\u0026ldquo;autonomy\\u0026rdquo; in the study, since we evaluated the \\u0026ldquo;perceived autonomy\\u0026rdquo; by fellows and would be determined by the respondent\\u0026rsquo;s perception and not by the investigator. Our sample size was determined by the number of responses and not by a power analysis. Given 64 IH and 59 non-IH respondents, doing a chi-square test on a yes/no outcome (such as agree/strongly agree versus all other responses), we would have 80% power, two-tailed, for a difference on the order of 50% versus 25% agree/strongly agree between the two groups. Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small. P values \\u0026lt;0.05 were considered significant. The institutional review board at Drexel University approved this study with a waiver of consent.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe survey was sent to 1041 subjects that were part of the TECaN list serve. However, not all members were eligible to take the survey, since some early career neonatologists had completed training more than 5 years ago. We report the results from 123 completed surveys that include responses from 82 fellows \\u0026amp; 41 early career neonatologists that graduated within the past 5 years. 52% trained in NICUs with IH attending coverage. 36% trained in institutions with attending HC model and 12% were from a mixed model where the attending stayed in house in certain situations.\\u003c/p\\u003e\\n\\u003cp\\u003eMost participants perceived the effect of IH attending coverage on patient care to be beneficial (Fig 1). However, when asked if the presence of attending in the NICU improved the fellow\\u0026rsquo;s education the responses divided almost equally between agree, neutral, and disagree (Fig1). More people in the IH attending model than the HC and Mixed Model (54.6% versus 15.2%) felt that having attending in house was beneficial for their education, p \\u0026lt; 0.05. \\u0026nbsp;The majority of respondents felt they had autonomy in their NICU (Fig1). However, more respondents in a model with IH attending disagreed with having autonomy, than those in HC and Mixed Model (10.9% versus 5%), p = 0.02.\\u003c/p\\u003e\\n\\u003cp\\u003eInterestingly, 30 of the 123 respondents experienced a change in model of attending coverage during their fellowship training. Among these 30 respondents, only 28% preferred having the model of attending IH coverage, while 14% commented on the benefits of both models. For instance, one subject responded that his/her preference, \\u0026ldquo;depended on the hospital- in an ECMO center, preferred in house attending call, while in a 70 bed Level III, preferred attending to be at home.\\u0026rdquo; The ACGME encourages programs to have a checklist that provides fellows with guidelines to suggest - when to call attending with situations/patient status changes(9). Only 30.9% of the respondents acknowledged having such a checklist.\\u003c/p\\u003e\\n\\u003cp\\u003eMost respondents perceived the reason for the increased attending presence to be better patient safety and having more help in emergent situations. Our survey participants acknowledged that programs with attending IH took certain measures to promote fellows\\u0026rsquo; autonomy that have been listed in Table 1. When asked about the factors that most influenced the fellows\\u0026rsquo; autonomy, our participants perceived them to be attendings\\u0026rsquo; preferences and fellows\\u0026rsquo; experience. Another respondent expressed that the autonomy was also affected by the division practices. For example, the respondent noted that, \\u0026ldquo;During residency their second-year resident supervised interns at meconium exposed deliveries. While as a fellow, they have an intern, resident, fellow and sometimes attending present at the delivery.\\u0026rdquo; In their opinion, \\u0026ldquo;It does not allow for autonomy and limits education. I feel it can be harmful after graduation when there is no longer someone physically present that is supervising you.\\u0026rdquo;\\u003c/p\\u003e\\n\\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cstrong\\u003eTable\\u003c/strong\\u003e 1: Fellows\\u0026rsquo; perception of IH attending coverage model\\u003c/p\\u003e\\n\\u003ctable style=\\\"border-collapse:collapse;border:none;\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 189.9pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 32.7pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;text-align:center;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003eQuestion\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 229.9pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 32.7pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;text-align:center;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003eMost frequent answers (number of respondents that chose the listed reason \\u0026ndash; could choose multiple reasons)\\u0026nbsp;\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 189.9pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 49.65pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003eMost important reason for switching to IH model\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 229.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 49.65pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e-Patient safety (37/123, 30.1%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e-Possible emergency situation that requires additional help (37/123, 30.1%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 189.9pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 82.35pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003eIn IH model, how does the program encourage fellow\\u0026rsquo;s autonomy\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 229.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 82.35pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e-Fellows encouraged to act independently/make a plan prior to consulting attending (79/123, 64.2%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e-Nurses encouraged to call fellow first (68/123, 55.3%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 189.9pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 33.9pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003eFactor influencing fellow\\u0026rsquo;s autonomy for decision making\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 229.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 33.9pt;vertical-align: top;\\\"\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e- Attending\\u0026apos;s preference (103/123, 83.7%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e- Fellow\\u0026apos;s experience (98/123, 79.7%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e- Patient pathology (87/123, 70.7%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;'\\u003e\\u003cspan style=\\\"color:black;\\\"\\u003e- Attending\\u0026rsquo;s age (49/123, 39.8%)\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp style='margin:0in;font-size:16px;font-family:\\\"Times New Roman\\\",serif;line-height:200%;'\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThere has been an ongoing debate about the effect of 24/7 intensivist coverage in critical care units in both adult and pediatric hospitals.(10) Numerous studies have been done in the PICU and pediatric cardiac ICUs to evaluate the effect of this on patient outcomes and house staff education.(7, 11) However there is a paucity of such investigations in the NICU and the published data is not very reliable. In our study we received responses from 123 fellows and early career neonatologist from 1041 subjects. Since some early career neonatologists had completed training more than 5 years ago, they were not eligible to take the survey and hence, our response rate of 11.8% is not accurate. We chose to compare the results of the IH group with the non-IH group, in which we combined the responses from HC and mixed model groups. Since, the mixed models were primarily home coverage and only did IH coverage in specific situations, we believe these groups were better placed together. This also allowed us to better perceive the opinion about IH coverage from respondents that only worked in that model vs. those that did not. The results from our survey suggest that most respondents perceive that concerns about patient care and safety have led to an increase in IH coverage. There are conflicting feelings regarding the benefits of IH coverage on fellow education, however more participants in the IH coverage model perceived it to be better for fellow education than participants in non-IH models.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eIn a previous study done to evaluate patient volume, staffing and workload in relation to risk adjusted outcomes; the UK Neonatal Staffing Study Group reported less nosocomial infections and quantitatively less death or brain damage with less neonatal consultant coverage.(5) In this study, the authors defined neonatal consultant coverage as pediatricians with more than 50% of their clinical sessions committed to neonatal care. In another study done in Canadian NICUs the investigators showed that units with in-house faculty or fellow coverage had lower nocturnal mortality rates relative to units with coverage by residents or other personnel.(12)\\u0026nbsp;Despite this unclear data, there is a vast majority of academic centers with fellows in training that are adapting the IH attending coverage model.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eIn a large observational study done using a virtual Pediatrics System Database, Gupta et al demonstrated that 24/7 IH attending coverage in the PICU is associated with improved overall patient care and survival after cardiac arrest compared with ICU\\u0026rsquo;s with HC model.(4) In a national survey of pediatric intensivists, pediatric critical care fellows and residents evaluating the perception of 24/7 IH attending on house staff education, only 50% of intensivists and 67% of house staff felt that house staff was well prepared for independent practice after training in an IH model of attending coverage. In this survey respondents currently working in IH models had a more favorable perceptions of the effects of IH coverage on house staff autonomy (P \\u0026lt; .0001), supervision (P \\u0026lt; .0001), and preparation for independent practice (P \\u0026lt; .0001) when compared with those training in HC models.(7)\\u0026nbsp;Similarly, in our survey respondents at institutions with IH coverage felt strongly that IH coverage was beneficial for fellows\\u0026rsquo; education when compared to respondents from institutions with HC and mixed model. This may be due to the respondent\\u0026rsquo;s familiarity with their model or that centers with IH model may have found ways to adapt to this changed model of attending coverage and utilize attending presence for improving the fellows educational experience. This may also suggest that there is a biased perception amongst respondents from institutions with HC model about the deleterious effects of IH coverage on fellows\\u0026rsquo; education.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eThe current guidelines of increased supervision requirement by ACGME (13) and recommendation of the society of Critical Care Medicine to have an intensivist led care of patients in the ICU have led to more institutes moving towards increased attending in house presence.(14) This increased attending presence in the NICU could provide an opportunity to improve fellows\\u0026rsquo; education. Another suggestion would be to encourage fellows to have a plan of action ready prior to consulting attendings and attendings could utilize this opportunity to convert the bedside clinical situation into a teachable moment.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eThere is a delicate balance between supervision and autonomy. In our survey, only 10 respondents felt that they did not have autonomy in their NICU. The fellows that felt lack of autonomy in their NICU were more likely to be training in centers with IH attending coverage. 83.7% of our respondents noted attending preference and 39.8% noted attending\\u0026rsquo;s age as factors influencing the level of autonomy, they get in their NICU. In a commentary about increased attending presence in the NICU, Jobe and Martin remarked, \\u0026ldquo;Younger attending physicians may be less comfortable in allowing physicians-in-training to make decisions, manage patients, and develop independence. Residents then become scribes for the clinical team rather than active participants, and fellows defer to attending physicians rather than making and defending decisions.\\u0026rdquo;(6)\\u003c/p\\u003e\\n\\n\\u003cp\\u003eFellowship programs have come up with different strategies to help provide fellows autonomy in the presence of IH attending. The most frequent strategies on how their program promoted fellows autonomy, involved: encouraging nurses to call the fellows first and encouraging fellows to make their own plan before calling the attending. Another suggestion could be for the attending to not be physically present in the unit during call. This would decrease the chances of the nurses approaching the attending with concerns directly and allowing them to be available promptly when the fellow needs help. In interest of patient safety, the ACGME recommends that fellowship program should have a checklist that provides fellows with guidelines for circumstances and events in which fellows must communicate with their supervising faculty(9). Only 30.9% of our respondents acknowledged having such a checklist. A better use of this tool may also help with addressing the issue of patient safety and balancing autonomy.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAlthough our study provides interesting and enlightening data, it is limited by the survey design and route of distribution. Since the TECaN list serve does not have a separate list for current fellows and early career neonatologists, we are unable to provide a response rate for current fellows who took this survey. Another limitation is the low response rate of the survey and may affect the validity of the results. The study also suffers from reporting bias since it is a self-reported survey and our ability to interpret the data. In addition this study only provides data about the perception of the respondents to change in attending coverage model. It does not objectively determine its effect on fellow competence, patient care and patient outcomes. However, it helps identify the major areas of concern with the perception of IH attending coverage in the NICU and can help guide programs to better address these concerns and implement measures to improve fellows\\u0026rsquo; educational experience. Based on the results from this survey a qualitative follow up study could be done, focusing on the fellows in HC model and analyze why they feel that attending presence would not be beneficial.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eConcern for patient care and safety have appropriately led to increased attending presence in the NICU. However, its impact on fellow education and autonomy are important considerations that have not been well studied. Our survey indicates that there are conflicting feelings regarding its benefit on training of neonatal fellows, however fellows training in IH model find it to be beneficial for their education. The centers undergoing this transformation should consider taking adequate measures to balance patient safety and fellow\\u0026rsquo;s autonomy as well as utilize the increased attending presence as a tool to improve fellows\\u0026rsquo; educational experience. \\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"List Of Abbreviations\",\"content\":\"\\u003cp\\u003eNICU: Neonatal Intensive Care Unit; IH: in house; ACGME: Accreditation Council for Graduate Medical Education; ICU: intensive care units; PICU: Pediatric Intensive Care Unit; TECaN: Training \\u0026amp; Early Career Neonatologists; HC: home coverage;\\u003c/p\\u003e\\n\"},{\"header\":\"Declarations\",\"content\":\"\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eEthics approval and consent to participate\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe Institutional Review Board (IRB) at Drexel University, Philadelphia, PA approved the study. The need for written consent was waived by the IRB.\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eConsent for publication\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAvailability of data and material\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCompeting interests\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eFunding\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eNo external funding\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAuthors\\u0026apos; contributions\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eMS conceptualized and designed the study, collected the data, carried out the statistical analysis and drafted the initial manuscript. AM conceptualized and designed the study, coordinated and supervised data collection, reviewed and revised the manuscript, and approved the final manuscript as submitted.\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAcknowledgements\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eWe thank Dr. Ed J. Gracely, PhD, for his assistance and guidance with the statistical analyses.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\n\\u003col\\u003e\\n\\u003cli\\u003eMercurio MR, Peterec SM. Attending physician work hours: ethical considerations and the last doctor standing. Pediatrics. 2009;124(2):758-62.\\u003c/li\\u003e\\n\\u003cli\\u003eBurnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. American journal of respiratory and critical care medicine. 2010;181(11):1159-60.\\u003c/li\\u003e\\n\\u003cli\\u003eIannucci GJ, Oster ME, Chanani NK, Gillespie SE, McCracken CE, Kanter KR, et al. The relationship between in-house attending coverage and nighttime extubation following congenital heart surgery*. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2014;15(3):258-63.\\u003c/li\\u003e\\n\\u003cli\\u003eGupta P, Rettiganti M, Rice TB, Wetzel RC. Impact of 24/7 In-Hospital Intensivist Coverage on Outcomes in Pediatric Intensive Care. A Multicenter Study. American journal of respiratory and critical care medicine. 2016;194(12):1506-13.\\u003c/li\\u003e\\n\\u003cli\\u003eTucker J. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet (London, England). 2002;359(9301):99-107.\\u003c/li\\u003e\\n\\u003cli\\u003eJobe AH, Martin RJ. 24/7 neonatal intensive care unit attending physician coverage: a clash of missions. American journal of respiratory and critical care medicine. 2010;182(6):729-31.\\u003c/li\\u003e\\n\\u003cli\\u003eRehder KJ, Cheifetz IM, Willson DF, Turner DA. Perceptions of 24/7 in-hospital intensivist coverage on pediatric housestaff education. Pediatrics. 2014;133(1):88-95.\\u003c/li\\u003e\\n\\u003cli\\u003eOwens ST, Owens GE, Rajput SH, Charpie JR, Kidwell KM, Mullan PB. Perceptions of 24/7 In-house Attending Coverage on Fellow Education and Autonomy in a Pediatric Cardiothoracic Intensive Care Unit. Congenital heart disease. 2015;10(3):E107-12.\\u003c/li\\u003e\\n\\u003cli\\u003eACGME speciality specific program requirements (Neonatal-Perinatal medicine).\\u003ca href=\\\"https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/329_NeonatalPerinatalMedicine_2019_TCC.pdf?ver=-02-19-133646-910\\\"\\u003ehttps://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/329_NeonatalPerinatalMedicine_2019_TCC.pdf?ver=-02-19-133646-910\\u003c/a\\u003e.\\u003c/li\\u003e\\n\\u003cli\\u003eArabi Y. Pro/Con debate: Should 24/7 in-house intensivist coverage be implemented? Critical Care. 2008;12(3):216-.\\u003c/li\\u003e\\n\\u003cli\\u003eAlfares FA, Jones MB, Ramakrishnan K, Endicott KM, Zurakowski D, Shankar V, et al. Perceptions of Bedside Cardiac Critical Care Registered Nurses on 24 Hour Attending Intensivist Coverage. Congenital heart disease. 2016;11(4):354-8.\\u003c/li\\u003e\\n\\u003cli\\u003eLee SK, Lee DS, Andrews WL, Baboolal R, Pendray M, Stewart S. Higher mortality rates among inborn infants admitted to neonatal intensive care units at night. J Pediatr. 2003;143(5):592-7.\\u003c/li\\u003e\\n\\u003cli\\u003eAccreditation Council on Graduate Medical Education.Common Program Requirements. Available at:.\\u003ca href=\\\"https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements\\\"\\u003ehttps://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements\\u003c/a\\u003e.\\u003c/li\\u003e\\n\\u003cli\\u003eHaupt MT, Bekes CE, Brilli RJ, Carl LC, Gray AW, Jastremski MS, et al. Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Critical care medicine. 2003;31(11):2677-83.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Education, Supervision, Autonomy, Neonatology, House staff, Survey\",\"lastPublishedDoi\":\"10.21203/rs.2.13983/v4\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.2.13983/v4\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eBackground\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\u003cp\\u003eThere is a current change in type of attending coverage in the Neonatal Intensive Care Unit (NICU) from home calls to 24/7 in House. Effects of this increased attending physician presence on education of NICU fellows has not been studied. The objective of this study is to evaluate the fellows’ perception of in house attending coverage on their education and evaluate its effect on their perceived autonomy.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eMethods\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\u003cp\\u003eA secure, anonymous, web-based survey was designed using RedCap. The web-based survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training \\u0026amp; Early Career Neonatologists. Questions were focused on perception of IH attending coverage on fellows’ educational experience including the respondent’s perceived ability to make independent decisions (autonomy). Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eResults \\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\u003cp\\u003eOne hundred and twenty-three surveys were analyzed, that included responses from 82 fellows \\u0026amp; 41 early career neonatologists. 52% reported having 24/7 attending in-house (IH) coverage. 30 of the 123 respondents experienced a change in model of attending coverage during their training. Among these 30, only 26.6% preferred the model of attending IH coverage. The respondents currently working in IH models, when compared to those in non-IH coverage models felt IH attending coverage was beneficial for fellow education (p \\u0026lt;0.05) but was less likely to give fellows autonomy for decision making (p=0.02).\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eConclusion\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\u003cp\\u003eIn our survey respondents with in house attending, had a more favorable view of its benefit on fellow education. Institutions practicing or considering IH attending coverage should consider use of adequate measures to balance fellow supervision and education.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Effect of 24/7 attending coverage in the Neonatal Intensive Care Unit on fellow education.\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":4,\"date\":\"2020-11-11 15:16:07\",\"doi\":\"10.21203/rs.2.13983/v4\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Accept\",\"date\":\"2020-11-09T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2020-11-05T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-11-04T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2020-11-04T23:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":3,\"date\":\"2020-10-15 18:15:30\",\"doi\":\"10.21203/rs.2.13983/v3\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Minor revision\",\"date\":\"2020-10-29T00:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-10-28T00:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Accept after minor essential revisions\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nPEER REVIEWER ASSESSMENTS:\\n\\nOBJECTIVE - Full research articles: is there a clear objective that addresses one or several testable research questions? (Brief or other article types: is there a clear objective?)\\nYes - there is a clear objective\\n\\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\\nYes - the approach is appropriate\\n\\nEXECUTION - Are the experiments and analyses performed with sufficient technical rigor to allow confidence in the results?\\nNo - there are minor issues\\n\\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\\nNo - there are issues with the statistics in the study\\n\\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\\nYes - the author's interpretation is reasonable\\n\\nOVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently for you to now recommend the work as a technically sound contribution? If not, can further revisions be made to make the work technically sound?\\nProbably - with minor revisions\\n\\nPEER REVIEWER COMMENTS:\\n\\nGENERAL COMMENTS: The study needs some revision.\\n\\nREQUESTED REVISIONS:\\nIn the abstract, methods part, line 24, the word 'using' is repeated.\\n\\nIn my earlier comment \\\"In methods part of the abstract, please add few lines explaining how the outcome of interest (perceived autonomy of fellow) defined and used in the study?\\\" the author answered that they did not specifically define 'autonomy' in their study which is fine. But, my question was the author should provide at least some info about how the outcome was defined, whatever the outcome is used in the study.\\n\\nIn another question, the author clarified that \\\"Chi-square tests were used to compare responses between groups\\\" but I still can't find where they have reported such results in their manuscript, please clarify.\\nADDITIONAL REQUESTS/SUGGESTIONS:\\nNo* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\\n* Is the presentation of the work clear?: **No**\\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\\n\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2020-10-27T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-10-27T12:00:00+00:00\",\"index\":1,\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2020-10-07T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-10-06T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2020-10-06T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":2,\"date\":\"2020-06-08 15:15:17\",\"doi\":\"10.21203/rs.2.13983/v2\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Major revision\",\"date\":\"2020-09-02T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-08-26T12:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Major revisions required\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nPEER REVIEWER ASSESSMENTS:\\n\\nOBJECTIVE - Full research articles: is there a clear objective that addresses one or several testable research questions? (Brief or other article types: is there a clear objective?)\\nYes - there is a clear objective\\n\\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\\nNo - there are minor issues\\n\\nEXECUTION - Are the experiments and analyses performed with sufficient technical rigor to allow confidence in the results?\\nNo - there are major issues\\n\\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\\nNo - there are issues with the statistics in the study\\n\\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\\nNo - there are minor issues\\n\\nOVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently for you to now recommend the work as a technically sound contribution? If not, can further revisions be made to make the work technically sound?\\nMaybe - with major revisions\\n\\nPEER REVIEWER COMMENTS:\\n\\nGENERAL COMMENTS: This is interesting topic of study which could be best understood in a qualitative design rather than in quantitative. However, looking at the study title, it is quantitative but still no sufficient quantitative information are provided in the manuscript to answer the study aim. By study design this should be a cross-sectional descriptive study, but the presentation of findings is not very thoughtful.\\n\\n\\nREQUESTED REVISIONS:\\nI have also looked the comments by other reviewer and the authors response which are satisfactorily answered. Some of the comments especially, C4 of R2 is not well addressed.\\nSome specific comments are presented below:\\nIn methods part of the abstract, please add few texts explaining how the outcome of interest (perceived autonomy of fellow) defined and used in the study?\\nIn the methods part, page 7, the authors say that they have used chi square test to compare groups on dichotomous outcomes. However, I can't find these results in the manuscript.\\nThe question used to ask respondents perception of the effect of attending presence in the NICU is not clear. I think the perception should be on attending presence in the NICU not really the perception of the effect.\\nADDITIONAL REQUESTS/SUGGESTIONS:\\nNo* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\\n* Is the presentation of the work clear?: **Yes**\\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\\n\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-08-20T12:00:00+00:00\",\"index\":1,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2020-06-19T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2020-06-01T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2020-05-31T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2020-05-31T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}},{\"code\":1,\"date\":\"2019-09-05 19:43:42\",\"doi\":\"10.21203/rs.2.13983/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Major revision\",\"date\":\"2020-05-01T12:00:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2020-03-26T12:00:00+00:00\",\"index\":2,\"fulltext\":\"Recommendation: Major revisions required\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nThe topic of what amounts to appropriate attending supervision in the NICU is interesting and timely. As the authors note, there has been an increase in mandates for attending access and presence, and while that's variable across different healthcare systems, it is an important factor in graduate medical trainee education.\\n\\nOne significant limiting factor is the return rate of the survey. This is noted below but warrants greater discussion and should color the strength of interpretation of the results.\\n\\nAbstract\\n1. While the conclusion that hospitals \\\"should consider\\\" balancing supervision and autonomy, the language of \\\"must\\\" is too strong based on the data that is provided. Would reword.\\n\\nProblem statement and research question.\\nThe introduction in this paper builds a logical case for why their research survey was needed. They note a discrepancy between data on NICU attending presence and outcomes, though this is the reason given for the move towards in-house coverage. The authors contrast the data from the NICU with PICU data, where it seems attending presence does improve outcome, but there is detriment to house staff independence. The hypothesis is clear.\\n\\nThe literature cited is appropriate however it should be referenced with each line.\\n1. Page 6, line 20 - Is there a specific reference for increasing attending presence in the ICU? This needs a reference\\n2. Page 6, lines 23 -28 - this also needs a specific reference\\n3. Page, line 35 - who has argued this? Needs a reference\\n\\nMethods\\n1. The study is based on a 13-question survey distributed through the TECaN network. The method section would be enhanced with more information regarding the survey development, as it's unclear what the scope of the questions were and of what quality they were, so we cannot review the validity of the questionnaire.\\n2. It seems that the questions were based on the expert author's opinions and experiences of what should be asked, but without mention of cognitive interviewing or pilot testing. Particularly, this study asks about both fellow education and autonomy, and it would be interesting to see how the authors separated these concepts, as it would make sense that the level of autonomy might impact education.\\n3. While the statistical analysis seems appropriate for the categorical data collected, the section required re-reading multiple times to understand and so clarifying the language here would make it easier to understand.\\n4. Similarly, there is language about how data was analyzed in the results section (re: how the Likert data was reduced to three groups) that perhaps should be in the methods section for clarity on how the data was prepared for analysis.\\n\\nResults\\nThe results are interesting, regarding the perception that attending presence was beneficial for patient care and, perhaps, fellow education, but clearly colored by participants' training experiences.\\n1. While you state that the number of people to whom the survey was sent were not all eligible, you need some kind of response rate. Based on what you report, it is about 12%. While you can explain why you think this is not quite right, you do need to acknowledge it and comment in the discussion about the impact of such a low rate of return.\\n2. Somewhere you need to explain why you lumped the mixed model with the HC model. This may be ok to do but it does have implications (that need to be discussed) and it was a choice (which needs to be discussed).\\n3. Table 1 needs to be reworked. It may make sense to have Figure 1 broken down also by attending coverage type (IH, HC, mixed).\\n4. The results section would be aided perhaps by a table with many of the analyses listed, given that there is discrepancy in the results reported and the figure shown.\\n5. The authors note that most participants felt they had appropriate autonomy (in fact, in Figure 1, this graph on autonomy shows overwhelming support that participants felt they had autonomy), and Figure 1 would suggest only about 8% did not agree. However, the authors then write that respondents with IH attending models more likely disagreed with having autonomy, citing a comparison of 10.9% vs 5% (page 9, line 17), and it's not clear where this comparison is coming from, though it might be that the 10 participants that chose \\\"disagree\\\" for this question were more likely to be in the IH group. This is not made clear. Moreover, if it is based on 10 people, it is unclear how \\\"true\\\" this finding is.\\n6. The data on the subset of fellows who went through an attending coverage transition is quite interesting. D\\n7. Page 9, line 31 - Reflection of the occasional quote does not make sense as the reader has no idea of the spectrum of responses. Would remove this in the results. Can be part of a discussion, perhaps but this is not a true \\\"result\\\" that should be reported without a full array of comments and an analysis of them.\\n8. Page 9, line 34 - you need to have a citation for this ACGME reference\\n9. Page 9, paragraph starting at line 46 - this descriptive of the results but some numbers should be included to demonstrate how strong these \\\"preferences\\\" were. Where are you getting the \\\"factors\\\" that you report? How common were these responses?\\nTables and Figures\\n1. Table 1 needs to be reworked. When you read it, is unclear why the \\\"n\\\" changes throughout. The questions should be on the left column with some kind of percentages listed to the right. The top row could be the different categories (IH, HC and Mixed) with the n's listed. This is just an idea but this is definitely not clear as it is.\\n\\nDiscussion\\n\\nOverall, this section would be strengthened by a stronger discussion of your results. Talk through what you found and give thoughts on how they might be interpreted with clear language that these ar interpretations and not fact.\\n\\n1. In the discussion, the authors start with reviewing the literature and conclusion that despite unclear data about attending coverage adding to patient safety and outcomes, that the reality is most academic centers are transitioning to that model Most of the literature review is better placed in the introduction or referenced after discussion of the study's findings. The discussion should lead with a discussion of your findings. They can then be put in context of other studies. Citing others' results in the same paragraph of this study's results is confusing to the reader and somewhat misleading.\\n2. Page 10, line 38 - this sentence is unclear \\\"\\\"not very variable\\\" is confusing.\\n3. Page 11, line 36 -The authors also note that there is discrepancy in respondents' opinions about the educational benefit of 24/7 coverage and that this may be based on the type of coverage with which the respondents were already familiar (home institution bias) - this point would be aided by the data from Figure 1 being shown in light of these differences and the strength of the language needs to be adjusted - you cannot say \\\"this can be attributed to\\\" as this is a hypothesis at best.\\n4. Page 12, lines 5-12 - again this is too strong of language. These are suggestions at best.\\n5. Page 12, line 24 - this is the first discussion of age in the paper. This should be presented in results if you are going to discuss it here. Additionally, citing a different paper/commenatry does not make sense in your discussion.\\n6. Page 12, paragraph starting at line 42 - would refrain from a discussion of your own program here. This is not a perspective piece. It is a report of data. You could propose some interventions that may help but not tell the story of your institution.\\n7. Your discussion of limitations is good. Would add what the impact of some of those limitations are on our ability to interpret the data. I think a low response rate has to be discussed here.\\n\\nConclusion\\n1. The authors conclude that autonomy and education need to be considered when transitioning a program to an IH coverage type. However their data suggests that while this might be true for education, autonomy was overwhelming preserved, regardless of the type of program (at least the way Figure 1 currently suggests) and that autonomy is more likely impacted by the data presented in Table 1 (attending preference, fellow experience) than by attending coverage type.\\n\\n2. In addition, would avoid theword \\\"should\\\" as that is too strong based on these data.\\n\\n\\n* Are the methods appropriate and well described?: **No**\\n* Does the work include the necessary controls?: **Yes**\\n* Are the conclusions drawn adequately supported by the data shown?: **No**\\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\\n* Quality of written English: **Needs some language corrections before being published**\\n* Declaration of competing interests: **I declare that I have no competing interests**\\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\\n\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2020-02-23T12:00:00+00:00\",\"index\":2,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2019-10-16T12:00:00+00:00\",\"index\":1,\"fulltext\":\"Recommendation: Accept after minor essential revisions\\nForm responses:\\n---\\n\\nComments to Author:\\n---\\nThis study addresses a very interesting topic, namely the effect of \\\"potential patient care improving changes\\\" on the autonomy and education of fellows.\\nI complement the authors for the relevance of the topic and their great writing style. The paper reads very nicely and grabbed my attention from the beginning.\\n\\nI have only two concerns:\\n\\n1) the methodology; to answer the research question, I believe you need in-depth insights into the participants in how they experience their fellowship. A survey can be a great start, but it is really needed to sit down with the fellow's and start finding the constructs and reasons that the participants have for answering the way they do. With this study, we now only know who preferred what, but the most important reason, namely why, we have no idea about. Are we looking at a change management problem? Are attending physicians less able or willing to educate during shifts? Are fellow's aware of the potentials benefits and pitfalls of this IH system? Questions that could have been answered with a qualitative study. The added value of this current paper to the available literature, without any new insights, is to my opinion minimal. Adding a qualitative evaluation after the survey could have done what.\\n\\n2) The main conclusion is; change needs to be evaluated. The authors write: \\\"..must use adequate measures to balance fellow supervision…\\\" but they do not address how to measure it. The paper really needs to give me an advice how the authors believe we should evaluate this balance, since there is no validated tool available to my knowledge.\\n* Are the methods appropriate and well described?: **No**\\n* Does the work include the necessary controls?: **Yes**\\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\\n* Quality of written English: **Acceptable**\\n* Declaration of competing interests: **I declare that I have no competing interests**\\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). 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