Complexity and Challenges of Cross-Cover Care in Graduate Medical Education: A Qualitative Study.

PURPOSE: Cross-cover care (care for hospitalized patients when the primary team is absent) is a common graduate medical education responsibility; however, it may lead to increased preventable adverse events. Despite understanding the difficulties of cross-cover care, medical educators lack comprehensive knowledge of specific challenges that residents face and how they handle these challenges. This study explores the challenges residents experience when providing cross-cover care. METHOD: The authors conducted 60 semistructured, qualitative interviews with 20 internal medicine and surgery residents at a single academic institution between October 2021 and April 2022. Each resident participated in 3 interviews, 2 immediately after a shift. Working inductively, the authors generated codes for important themes. Study design and data collection were guided by interpretive description, a qualitative approach for health care research focused on experiences and perceptions to develop meaningful findings. To illustrate residents' workflow and aid in quality improvement efforts, the authors created a process map. RESULTS: Seventeen cross-cover challenges were organized into 7 interrelated and overlapping themes: lack of baseline knowledge, inadequate or inaccurate information transfer from the primary team, unfamiliarity with cross-cover patients, high task volume leading to increased interruptions, ill-defined roles leading to unmet expectations from others, perceived decreased access to resources, and fatigue. The process map illustrates 4 cross-cover workflow components: information transfer from the primary team to the cross-cover team, direct handling of cross-cover tasks that are assigned by the primary team or that arise during the time of cross-cover, information transfer back to primary team and other care team members, and responsibilities that residents have overnight that are not directly related to cross-cover. CONCLUSIONS: Residents face substantial challenges when providing cross-cover care, which have important implications for patient safety and resident well-being. The medical community should strive to develop educational and structural interventions to improve this process.

Transition to Residency Courses: Recommendations for Creation and Implementation.

Transition to Residency (TTR) courses help ease the critical transition from medical school to residency, yet there is little guidance for developing and running these courses. In this perspective, the authors use their expertise as well as a review of the literature to provide guidance and review possible solutions to challenges unique to these courses. TTR courses should be specialty-specific, allow for flexibility, and utilize active learning techniques. A needs assessment can help guide course content, which should focus on what is necessary to be ready for day one of residency. The use of residents in course planning and delivery can help create a sense of community and ensure that content is practical. While course assessments are largely formative, instructors should anticipate the need for remediation, especially for skills likely to be performed with limited supervision during residency. Additionally, TTR courses should incorporate learner self-assessment and goal setting; this may be valuable information to share with learners' future residency programs. Lastly, TTR courses should undergo continuous quality improvement based on course evaluations and surveys. These recommendations are essential for effective TTR course implementation and improvement.

The power of written word: Reflection reduces errors of omission.

BACKGROUND: Medical trainees are expected to perform complex tasks while experiencing interruptions, which increases susceptibility to errors of omission. In our study, we examine whether documentation of clinical encounters increases reflective thinking and reduces errors of omission among novice learners in a simulated setting. METHODS: In 2021, 56 senior medical students participated in a simulated paging curriculum involving urgent inpatient cross-cover scenarios (sepsis and atrial fibrillation). Students responded to pages from standardized registered nurses (SRNs) via telephone, gathered history, and discussed clinical decision-making. Following the phone encounter, students documented a brief note (documentation encounter). A 'phone' score (number of checklist items completed in the phone encounter) and a 'combined' score (number of checklist items completed in the phone and documentation encounters) were calculated. Data were analyzed for differences between the phone scores (control) and combined scores using T-tests and McNemar test of symmetry. FINDINGS: Fifty-four students (96%) participated. Combined scores were higher than phone scores for sepsis (72.8 ± 11.3% vs. 67.9 ± 11.9%, p < 0.001) and atrial fibrillation (74.0 ± 10.1% vs. 67.6 ± 10.0%, p < 0.001) cases. Important items, such as ordering blood cultures for sepsis (p = 0.023) and placing the patient on telemetry for atrial fibrillation (p = 0.013), were more likely to be present when a note was documented. DISCUSSION: This study suggests that documentation provides a mechanism for learners to reflect, which could increase important diagnostic and therapeutic interventions. CONCLUSION: Documentation by novice medical learners may improve patient care by allowing for reflection and reducing errors of omission.

Important Leadership Skills and Benefits of Shared Leadership Training for Chief Residents: A Delphi Analysis.

Background: Chief residents (CRs) have pivotal educational and leadership roles in residency programs. The necessary CR leadership skills that transcend specialties have not been defined and most training on these skills occurs in silo. Objective: The primary goal was to define leadership skills important for the general CR role. The secondary aim was to determine which skills should be included in cross-specialty CR training and identify benefits of such training. Methods: Sixty-three CRs and 25 program directors (PDs) from 25 residency programs at a single institution were surveyed via a modified Delphi approach in 2022 as part of a needs assessment on CR leadership training. First, respondents answered three open-ended questions about skills needed for the CR role and the potential benefits of cross-specialty CR training. Respondents then rated categorized responses on the importance of the skill, agreement that skills should be included in cross-specialty training, and agreement on benefit of cross-specialty training using a 5-point Likert scale. Positive consensus was defined as 80% agreement. Results: Fifty respondents (53%) participated in round one and 28 (32%) in round two. Positive consensus was reached on 38 skills (63%). Nine skills reached consensus on inclusion in cross-specialty training including communication skills and certain management skills. Consensus on benefits of training include learning from and collaborating with other residency programs. Conclusion: The authors defined important skills for the CR role that reached consensus across a broad range of specialties and identified the perceived benefits of shared leadership training. Residency programs should consider cross-specialty leadership training for CRs with a focus on communication and management skills.

Enhancing Resident Education by Embedding Improvement Specialists Into a Quality and Safety Curriculum.

Background: Quality improvement and patient safety (QIPS) curricula are critical in graduate medical education, yet barriers limit the educational experience and project outcomes. Objective: To explore the impact of QIPS curricular enhancements and integration of continuous improvement specialists (CIS) by examining the A3 document, the primary project product and surrogate for project quality. Methods: Since 2009, University of Michigan internal medicine and medicine-pediatric residents participate in a QIPS curriculum, which includes a 4-week group project. In 2016, residency leaders collaborated with CIS staff, non-clinical experts in QIPS with backgrounds in engineering and business, to improve the curriculum. Informed by a needs assessment, the intervention was implemented in 2017 and consisted of a set of enhancements including integration of CIS staff into groups as co-facilitators. In this retrospective cohort study, a blinded reviewer evaluated all available A3 documents before and after the intervention using a quantitative analysis tool. Results: All residents participated in the curriculum during the pre-intervention (July 2009 to June 2016, n=351) and post-intervention (July 2017 to June 2020, n=148) periods. A total of 23 of 84 (27%) pre-intervention and 31 of 34 (91%) post-intervention A3 documents were available for review. Scores improved significantly for 17 of 23 (74%) A3 items and for 7 of 8 (88%) sections. Mean A3 total scores increased from 29.0 to 47.0 (95% CI 12.6-23.4; P<.001) out of a possible 69.0. Conclusions: Embedding CIS experts into residency QIPS curricula is associated with improved A3 document quality.

Can Incoming Interns Be Entrusted to Recognize Medical Emergencies? Implementation of a Vignette-Based Cross-Cover Assessment.

Background: Interns must recognize urgent clinical situations and know when to seek assistance. However, assessing this skill is challenging. Objective: We explored whether graduating medical students could determine urgency of medical cross-cover scenarios and what factors were associated with this ability. Methods: Sixty senior medical students enrolled in an internal medicine residency preparation course, and 28 experts were invited to take an assessment using 4 clinical vignette handoffs, each with 5 to 6 cross-cover scenarios. Respondents were asked whether they would evaluate the patient at bedside and notify their supervising resident. They were asked to rate their comfort managing the scenario, rate the urgency (1=low, 2=moderate, 3=high), and take a medical knowledge quiz. Student performance was categorized based on stratification of clinical urgency-those who underestimated (fourth quartile), accurately estimated (second and third quartile), and overestimated (first quartile) urgency. We examined differences between groups in medical knowledge, action, and confidence using analysis of variance and post-hoc Tukey Honestly Significant Difference test. Results: Fifty-eight students (96.7%) and 22 experts (78.6%) participated. Clear differentiation emerged between students' ability to estimate urgency on the 3-point urgency scale (lowest quartile: 2.15±0.11; mid-quartiles: 2.38±0.07; upper quartile: 2.61±0.10, respectively). Students who underestimated urgency were less likely to notify their supervising resident (P=.001) and less likely to evaluate a patient at bedside (P=.01). There was no difference in quiz score or comfort level. Conclusions: Incoming interns vary in their abilities to recognize urgent scenarios, independent of medical knowledge and confidence.

"Patient's Family Wants an Update": A Curriculum for Senior Medical Students to Deliver Telephone Updates for Hospitalized Patients.

Introduction: Residents have the important task of updating family members of hospitalized patients, often by telephone. There are limited curricula dedicated to preparing medical students for this task, which will become their responsibility as residents. Methods: We created a virtual workshop, including four patient cases, to facilitate teaching senior medical students enrolled in an internal medicine residency preparation course. Students alternated role-playing either physician or family member. We assessed performance using a self-assessment rubric before (preworkshop) and after (postworkshop) a didactic session. We compared pre- and postworkshop scores using t tests. We also used a retrospective pre-post survey with a 5-point Likert scale to assess each participant's comfort level, knowledge, and perceived ability. Results: Thirty-nine students completed the pre- and postworkshop evaluation (response rate: 70%). The mean score on the preworkshop self-assessment was 83% (SD = 9%) and on the postworkshop self-assessment was 94% (SD = 8%; p < .01), with a large effect size of 1.22. Among the 31 students (62%) who completed the survey, there was improvement in comfort level (2.9 vs. 3.7, p < .001), knowledge (2.7 vs. 3.8, p < .001), and perceived ability (2.9 vs. 3.7, p < .001). Discussion: Our workshop was effective in teaching medical students a structured format for providing telephone updates and was well received. The workshop was also effective when delivered virtually (with videos off) to mimic the non-face-to-face communication that occurs when delivering family updates by telephone. The curriculum could be expanded to other learner groups.

Interprofessional experiences to bridge the medical school to residency transition: a pilot program.

Interprofessional experiences during medical school are often delivered during pre-clinical years, but less is known about the value of clinical students. Our institution implemented a specialty-specific interprofessiona curriculum during Residency Preparation Courses (RPCs) for senior students including didactics, clinical experiences, and a simulated paging curriculum. Our aim was to determine whether this intervention improved perceptions of interprofesiona roles. We distributed anonymous surveys before (pre-survey) and after (post-survey, collected within 2 weeks of course completion) the RPC to 90 students with questions related to interprofessional roles using a 5-point scale (1 = strongly disagree, 5 = strongly agree). Three months after the start of residency, we sent follow-up surveys inquiring about the usefulness of RPC components (1 = not at all useful, 5 = extremely useful). Response rates were 84.4% pre-survey, 63.3% post-survey, and 41.1% follow-up survey. Post-surveys indicated improvement in self-reported ability in all domains: understanding one's contributions to interprofessional teams (3.9 to 4.4, p < .0001), understanding other team members' contributions (3.9 to 4.4, p < .0001), learning from interprofessional team members (4.2 to 4.6, p = .0002), accounting for interprofessional perspectives (4.2 to 4.6, p < .0001), and co-developing effective care plans (3.9 to 4.4, p < .0001). Follow-up surveys rated clinical experiences as slightly-to-moderately useful (2.3 ± 1.0) and paging curriculum very-to-extremely useful (4.3 ± 1.0). This study demonstrates the value of interprofessional education for advanced students.

The Development of a Video Intervention to Improve Senior Medical Students' Performance on Outpatient Telephone Encounters: a Delphi Analysis and Randomized Controlled Trial.

Introduction: Postgraduate trainees address outpatient telephone calls (OTCs) with little prior training. This study determines the skills necessary for OTCs and examines whether a video intervention improves medical students' performance on simulated OTCs. Materials and Methods: We utilized a Delphi technique to determine skills needed for OTCs and created a 9-min video teaching these skills. Senior medical students were randomized to Intervention (viewed video) and Control (did not view video) groups. Students were assessed pre-/post-intervention on simulated OTCs. The primary outcome was the between-group difference in improvement. Results: The Delphi yielded 34 important skills with the highest focus on communication (n = 13) and triage (n = 6). Seventy-two students completed assessments (Control, n = 41; Intervention, n = 31). The score (mean ± SD) improved 4.3% in the Control group (62.3 ± 14.3% to 66.6 ± 25.0%) and 12.2% in the Intervention group (60.7 ± 15.2% to 72.9 ± 20.4%, p = 0.15). The effect size measured by Cohen's d was 0.55, considered effective (> 0.33) for an educational intervention. Conclusions: This project fills a gap in OTC training. The use of the Delphi technique, intervention development based on the results, and evaluation of efficacy is a process that could be reproduced for other educational gaps. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01331-w.

Student Perceptions of educational handovers.

BACKGROUND: Educational handovers can provide competency information about graduating medical students to residency program directors post-residency placement. Little is known about students' comfort with this novel communication. OBJECTIVE: To examine graduated medical students' perceptions of educational handovers. METHODS: The authors created and distributed an anonymous survey to 166 medical students at a single institution following graduation in the spring of 2018. Within this cohort, 40 students had an educational handover sent to their future program director. The survey explored comfort level with handovers (1=very uncomfortable; 5=very comfortable) and ideal content (e.g., student strengths, areas for improvement, goals, grades received after residency application). Respondents self-reported their performance in medical school and whether a handover was sent. Correlation analyses examined relationships between performance and other variables. T-tests examined differences between students who did and did not have a handover letter sent. RESULTS: The survey response rate was 40.4% (67/166) - 47.8% of students felt comfortable with handovers, 19.4% were neutral, and 32.8% were uncomfortable. There was no correlation between self-reported medical school performance and comfort level. Respondents felt most strongly that strengths should be included, followed by goals. Those who had a handover letter sent expressed significantly higher comfort level (3.8 ± 1.0 vs. 2.6 ±1.3, p=0.003) with this communication. CONCLUSION: Medical students reported varying levels of comfort with educational handovers; however, those who had handovers sent had more positive perceptions. In order to improve the education continuum, it is essential to engage students in the development of this handover communication.

Trainees' Perceptions of the Transition From Medical School to Residency.

BACKGROUND: There is emerging evidence that learners may be suboptimally prepared for the expectations of residency. In order to address these concerns, many medical schools are implementing residency preparation courses (RPCs). OBJECTIVE: We aimed to determine trainees' perceptions of their transition to residency and whether they felt that they benefited from participation in an RPC. METHODS: All residents and fellows at the University of Michigan (n = 1292) received an electronic survey in July 2018 that queried respondents on demographics, whether medical school had prepared them for intern year, and whether they had participated in an RPC. RESULTS: The response rate was 44% (563 of 1292) with even distribution across gender and postgraduate years (PGYs). Most (78%, 439 of 563) felt that medical school prepared them well for intern year. There were no differences in reported preparedness for intern year across PGY, age, gender, or specialty. Overall, 28% (156 of 563) of respondents participated in an RPC and endorsed feeling prepared for intern year, which was more than RPC non-participants (85% [133 of 156] vs 70% [306 of 439], P = .029). Participation in longer RPCs was also associated with higher perceived preparedness for residency. CONCLUSIONS: This study found that residents from multiple specialties reported greater preparedness for residency if they participated in a medical school fourth-year RPC, with greater perceptions of preparedness for longer duration RPCs, which may help to bridge the medical school to residency gap.

Cross-Cover Curriculum for Senior Medical Students.

Introduction: Cross-cover, the process by which a nonprimary team physician cares for patients, usually during afternoons, evenings, and weekends, is common in academic medical centers. With the advent of residency duty-hour restrictions, cross-cover care has increased, making education in effective cross-coverage an urgent need. Methods: We implemented a cross-cover didactic activity composed of 18 interactive cases with 29 senior medical students enrolled in an internal medicine residency preparation course. The curriculum was facilitated by one faculty member and one senior medical resident and utilized think-pair-share learning techniques to discuss an approach to a range of common (both urgent and routine) cross-cover scenarios. We analyzed confidence and feelings of preparedness pre- and postintervention. We also examined differences in medical knowledge based on two multiple-choice written cross-cover cases that addressed both medical management and triage. Results: This curriculum significantly improved feelings of confidence (from 1.8 to 3.2, p < .0001), reduced anxiety (from 4.5 to 4.1, p < .03), and improved performance in clinical case scenarios (from 82% to 89%, p < .02). Discussion: This curriculum covered not only the important medical aspects of cross-cover care (e.g., diagnostics and management) but also equally important roles of cross-cover, such as how to effectively triage cross-cover scenarios. The curriculum was well received by students.

Internal medicine paging curriculum to improve physician-nurse interprofessional communication: a single center pilot study.

Effective physician-nurse communication is critical to patient safety, yet internal medicine trainees are rarely given feedback on this skill. In order to address this gap, we developed a 4-week simulated paging curriculum for senior medical students. Standardized Registered Nurses administered five acute inpatient paging cases to students via telephone and scored communication on a 10-point global scale (1 = highly ineffective to 10 = highly effective) and seven communication domains using a 5-point Likert-type scale. The domains included precision/clarity, instructive, directing, assertive, ability to solicit information, engaged, and structured communication. Students received verbal and written feedback from the nurses on communication skills and clinical decision-making. Our primary goal was to determine if student-nurse communication improved throughout the curriculum. Data were analyzed using multivariate ANOVAs with repeated measures. Twenty-seven students participated. Global communication scores increased significantly from case 1 to case 5 (7.1 to 8.7, p < .01). The following communication domains increased significantly: precision (3.8 to 4.4, p < .01), instructive (3.6 to 4.7, p < .01), directing (4.0 to 4.6, p = .02), assertiveness (4.0 to 4.7, p = .04), engaged (4.1 to 4.7, p < .01). In conclusion, this curriculum can be an innovative approach to improve physician-nurse communication using standardized registered nurses to deliver structured feedback to medical trainees.

The 'July Effect' in supervisory residents: assessing the emotions of rising internal medicine PGY2 residents and the impact of an orientation retreat.

Background: The arrival of new residents brings challenges for residency programs and residents. Many residency programs conduct orientation sessions to help transition rising supervisory residents into their new roles, but no evaluation of their impact on residents' emotional well-being has been performed.Objective: This study assesses the impact of a half-day orientation retreat on rising internal medicine post-graduate year (PGY) 2 residents' emotions toward PGY2 year and their self-confidence in fulfilling the supervisory resident role.Design: A survey was administered to a class of rising supervisory residents immediately before and after an orientation retreat in May 2017. The survey provided participants an open-ended prompt to describe their emotions toward PGY2 year and a 5-point Likert scale to rate their confidence in fulfilling supervisory resident roles. Differences were assessed using McNemar's exact and Wilcoxon signed-rank tests, respectively.Results: Forty-four of 50 (88%) eligible participants completed pre- and post-intervention Likert scales and 40 of 50 (80%) eligible participants completed corresponding emotion sections. Pre-intervention the most common emotions were anxiety (n = 33, 82.5%) and excitement (n = 32, 80.0%). Post-intervention, participants' fear was reduced (45.0% vs 12.0%; p < 0.001). Participants reported greater confidence that internship prepared them for PGY2 year and understanding of triaging and admitting principles (agree or strongly agree from 65.9% to 84.0% and from 25.0% to 68.2%, respectively; p < 0.005 for improvement by Wilcoxon signed-rank for both).Conclusions: Orientation retreats may be an effective way to reduce fear and demystify the supervisory resident role.

Inpatient Cross-Cover Consensus Recommendations for Medical and Surgical Residents: A Delphi Analysis.

BACKGROUND: Residents regularly care for hospitalized patients for whom they are not the primary provider (cross-cover), often without guidance. OBJECTIVE: We identified and defined components of safe cross-cover care. METHODS: Sixty medical and surgical faculty physicians and chief residents from the Midwest were invited to participate in a Delphi study analyzing the appropriateness of cross-covering residents evaluating patients at bedside, deferring issues to the primary team, documenting a note, contacting the attending, and communicating with nurses. The first survey was free text, and responses were categorized. In the second survey, physicians rated categorized responses based on appropriateness using a 5-point Likert scale. High consensus was defined as ≥ 80% agreement, approaching consensus as 51% to 79% agreement, and nonconsensus as ≤ 50% agreement. Results were analyzed by specialty and cross-cover experience in the past year using Pearson χ2 test or Fisher exact test. RESULTS: Forty respondents (67%) completed the first survey and 30 (50%) completed the second. Responses led to 46 categories. Twenty-eight items (60%) achieved high consensus, 8 (17%) approached consensus, and 10 (22%) did not achieve consensus, with no difference based on specialty or experience. Responses with 100% consensus included: residents should evaluate a patient at bedside whenever asked by the nurse; documentation should occur for change in level of care, death, code, or rapid response team activation; and physician-nurse communication should be respectful and closed loop. CONCLUSIONS: This regional physician panel reached consensus on 28 elements important in cross-cover care, which can be used for training and future studies.

Cross-Cover Documentation: Multicenter Development of Assessment Tool for Quality Improvement.

Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. Background: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. Approach: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts. We measured interrater reliability of the tool and scored cross-cover note quality for hospitalized patients with overnight rapid response team activation on internal medicine services at 2 academic hospitals for 1 year. Patients with a code blue or a clinically insignificant event were excluded. The presence of a note, writer identity (resident or faculty), time from rapid response to documentation, note content (subjective and objective information, diagnosis, and plan), and patient outcomes were compared. Results: The instrument included 8 items to determine quality of cross-cover documentation: reason for physician notification, note written within 6 hours, subjective and objective patient information, diagnosis, treatment, level of care, and whether the attending physician was notified. The mean Cohen's kappa coefficient demonstrated good interrater agreement at 0.76. The instrument was scored in 222 patients with cross-cover notes. Notes documented by faculty scored higher in quality than residents (89% vs. 74% of 8 items present, p < .001). Cross-cover notes often lacked subjective information, diagnosis, and notification of attending, which was present in 60%, 62%, and 7% of notes, respectively. Conclusions: This study presents reliability evidence for an 8-item assessment tool to measure quality of documentation of cross-cover events and indicates improvement is needed for cross-cover education and safe transitions of care in acutely decompensating medical patients.

Does Performance on Evidence-Based Medicine and Urgent Clinical Scenarios Assessments Deteriorate During the Fourth Year of Medical School? Findings From One Institution.

PURPOSE: The fourth year of medical school (M4) should prepare students for residency yet remains generally unstructured, with ill-defined goals. The primary aim of this study was to determine whether there were performance changes in evidence-based medicine (EBM) and urgent clinical scenarios (UCS) assessments before and after M4 year. METHOD: University of Michigan Medical School graduates who matched into internship at Michigan Medicine completed identical assessments on EBM and UCS at the beginning of M4 year and 13 months later during postgraduate year 1 (PGY1) orientation. Individual scores on these assessments were compared using paired t test analysis. The associations of academic performance, residency specialty classification, and initial performance on knowledge changes were analyzed. RESULTS: During academic years 2014 and 2015, 76 students matched into a Michigan Medicine internship; 52 completed identical EBM stations and 53 completed UCS stations. Learners' performance on the EBM assessment decreased from M4 to PGY1 (mean 93% [SD = 7%] vs. mean 80% [SD = 13%], P < .01), while performance on UCS remained stable (mean 80% [SD = 9%] vs. mean 82% [SD = 8%], P = .22). High M4 performers experienced a greater rate of decline in knowledge level compared with low M4 performers for EBM (-20% vs. -4%, P = .01). Residency specialty and academic performance did not affect performance. CONCLUSIONS: This study demonstrated degradation of performance in EBM during the fourth year and adds to the growing literature that highlights the need for curricular reform during this year.

Are medical students trained in cross-cover?

OBJECTIVES: To examine the current state of cross-cover education in undergraduate medical education and intern perceived readiness to provide cross-cover. METHODS: An electronic survey was distributed to 126 incoming interns in surgery, internal medicine, family medicine and paediatrics residencies at a single academic centre. Information regarding prior cross-cover training, experience, confidence, and responses to a sample cross-cover case were obtained. RESULTS: The survey response rate was 69.8% (88 of 126), which included both partial and complete responses. Fifty-seven interns out of 85 (67.1%) had no formal training and 51 (60.0%) had no experience performing cross-cover. They reported feeling unprepared to provide cross-cover, with an average score of 1.8 on a 5-point Likert scale (1, not at all confident; 5, extremely confident). Interns had more confidence in performing cross-cover tasks if they had prior direct cross-cover experience (p = 0.001), and were the least confident in performing the initial evaluation and management of urgent issues (Likert score = 1.6). Scores on the sample case were correlated with the amount of prior experience with patients (p = 0.06). Only 77.7% of interns indicated that they would notify their senior resident in two urgent scenarios. Those who reported higher confidence in knowing when to ask for help were more likely to appropriately notify their senior colleague (p = 0.005). We identified gaps in cross-cover training and in the preparedness of incoming interns CONCLUSIONS: We identified gaps in cross-cover training and in the preparedness of incoming interns. This has important implications for the first day of residency, when interns are often asked to perform cross-coverage, yet feel unprepared to do so and express the greatest concern in urgent cross-cover scenarios. Addressing this curricular gap is crucial in assuring safe cross-cover care.