Study Setting and Participants

Inspired by the Choosing Wisely campaign,²² our study was conceived, initiated, and directed by residents with support of the Section on General Internal Medicine faculty. We conducted the study at a large academic medical center, and our institutional review board approved the study protocol. All internal medicine residents and all hospitalists on general medicine services who cared for approximately 120 patients daily were included in this study.

Each of the 3 resident teaching teams was structured with 1 faculty member from either general internal medicine or infectious diseases, 1 senior internal medicine resident, and 2 interns caring for up to 16 patients per team. Each member of the team was capable of ordering or discontinuing laboratory tests independent of other team members, but the majority of orders were placed by interns. By contrast, hospitalists worked as individual providers, with approximately 70 patients distributed equally among colleagues. When hospitalists supervised a resident teaching team, they were counted as part of the academic service tally. The structure of all teams remained constant during the entire study period, but individual team members changed monthly (resident teams) or weekly (hospitalist teams). Resident team members changed every 4 weeks having 2 days overlap with new resident teams transferring from subspecialty services, outpatient rotations, or possibly other general medicine teaching teams as per the usual rotation schedule. Most residents were exposed to our study intervention for only 4 weeks, but a minority was exposed for 8 weeks. Hospitalists worked 7 days on, 7 days off, with new hospitalists transferring from a previous hospitalist general medicine service, general medicine teaching service, and subspecialty service as per their usual schedule; the majority were exposed to our study for several weeks.