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J Gen Intern Med. 2009 Sep;24(9):1018-22. doi: 10.1007/s11606-009-1045-2. Epub 2009 Jul 5.

Association between hand-off patients and subject exam performance in medicine clerkship students.

Author information

  • 1University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box MED-HMD, Rochester, NY 14642, USA. Valerie_Lang@urmc.rochester.edu



Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students.


To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance.


Observational study over 1 year.


Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems.


Primary outcome: Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores.


Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34).


Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.

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