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Cherry Picking Patients – Resident Self-Assignment Pitfalls

March 19, 2021

Written by Nicole McCoin

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Resident characteristics, in particular gender and training specialty, were shown in this study to be associated with preferential patient self-assignment. Male residents were less likely to see breast-related chief complaints or vaginal bleeding. Off-service residents were more likely to see familiar chief complaints (e.g. surgery residents signing up for lacerations).

Why does this matter?
If we know that preferential patient self-assignment is happening and that it is potentially detrimental to patient care, patient experience, and resident education, perhaps we should consider moving to a different way of assigning patients. This could be a rotational patient assignment or an even more sophisticated approach in which trainees are assigned to chief complaints with which they have had less exposure.

Cherry picking is for the birds
This study looked at a limited scope of chief complaints, resident characteristics, and patient self-assignment. In particular, chief complaints of vaginal bleeding, breast-related concerns, male genitourinary concerns, gastrointestinal bleeding, epistaxis, and laceration were studied. The authors looked at 9 years of data from one tertiary academic medical center and determined the likelihood of patients with each of these six chief complaints receiving treatment by a male or female resident or a certain training specialty. Male residents were significantly less likely than female residents to treat patients with breast-related chief complaints, with an adjusted odds ratio of 0.67 (95% CI 0.54-0.83, p<0.001). Male residents were also significantly less likely than female residents to treat patients presenting with a chief complaint of vaginal bleeding, with an adjusted odds ratio of 0.73 (95% CI 0.63-0.84, p<0.001). Surgery residents were more likely to see patients with lacerations, with an adjusted odds ratio of 2.11 (95% CI 1.71-2.61, p<0.001). OB GYN residents were less likely to see patients with male genitourinary concerns, with an adjusted odds ratio of 0.21 (95% CI 0.05-0.85, p=0.029).

This study looked at the tip of the iceberg, or should I say just one limb of the entire cherry tree. Only six chief complaints were studied. The authors did not account for non-binary gender identification in either the residents or the patients. We do not know all the factors at play or reasons why this potential cherry picking occurred. We also can hypothesize how much this affects a clinician’s performance and patient care months to years later after training is completed; however, further exploration into this was not within the scope of this study.

What we can conclude is that we need to give considerable thought to how residents are assigned to patients and what their clinical experience looks like on a shift to shift basis. We also can bring the data in studies like this one to light and have open discussion about cherry picking and the many ways in which it may be detrimental. Perhaps using this article as a springboard for discussion will be fruitful (no pun intended).

Association of resident characteristics with patterns of patient self-assignment. Am J Emerg Med. 2021 Jan 31;44:112-115. doi: 10.1016/j.ajem.2021.01.081. Online ahead of print.

What are your thoughts?