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no gastrointestinal or respiratory symptoms, including cough Author Affiliations: Department of Medical Imaging, Henan Provincial People’s and sore throat, reported or observed by the . Chest , Zhengzhou, Henan, China (Bai, Chen, Wang); Department of Radiology, Anyang Hospital of Traditional Chinese , Anyang, Henan, CT images on January 27 and 31 showed no significant abnor- China (Yao); Department of Radiology and Interventional, the Fifth People's malities. Her C-reactive protein level and lymphocyte count Hospital of Anyang, Anyang, Henan, China (Wei); Tianjin Medical University were normal (Table). Results of RT-PCR testing were negative Cancer Institute and Hospital, Tianjin, China (Tian); Li Ka Shing Faculty of on January 26, positive on January 28, and negative on Medicine, the University of Hong Kong, Pokfulam, Hong Kong, China (Jin). February 5 and 8. Corresponding Author: Meiyun Wang, MD, PhD, Department of Medical Imaging, Henan Provincial People’s Hospital and the People’s Hospital of 2 through 6 developed COVID-19. Four were Zhengzhou University, No. 7, WeiWu Road, Zhengzhou 450003, Henan, China women, and ages ranged from 42 to 57 years. None of the pa- ([email protected]). tients had visited Wuhan or been in contact with any other Published Online: February 21, 2020. doi:10.1001/jama.2020.2565 people who had traveled to Wuhan (except 1). Author Contributions: Drs Yao and Wang had full access to all of the data in the Patients 2 through 5 developed fever and respiratory symp- study and take responsibility for the integrity of the data and the accuracy of toms between January 23 and January 26 and were admitted the data analysis. Drs Bai, Yao, and Wei contributed equally to the work. Concept and design: Bai, Yao, Tian, Jin, Wang. to the hospital on the same day. All patients had RT-PCR test re- Acquisition, analysis, or interpretation of data: Bai, Yao, Wei, Tian, Chen, Wang. sults positive for COVID-19 within 1 day. Patient 6 developed fe- Drafting of the manuscript: Bai, Yao, Wei, Tian, Wang. ver and sore throat on January 17 and went to the local Critical revision of the manuscript for important intellectual content: Bai, Tian, Jin, Chen, Wang. for treatment. There was no report of COVID-19 at the clinic. Her Statistical analysis: Bai, Chen, Wang. symptoms improved over the next few days but worsened on Administrative, technical, or material support: Bai, Yao, Wei, Tian, Wang. January 24, when she was admitted to the hospital and con- Supervision: Tian, Wang. firmed to have COVID-19 on January 26. Two patients devel- Conflict of Interest Disclosures: None reported. oped severe pneumonia; the other infections were moderate. Additional Contributions: We thank Taiyuan Liu, MD, Rushi Chen, MD, and Wei All symptomatic patients had multifocal ground-glass Wei, MD (Henan Provincial People’s Hospital and the People’s Hospital of Zhengzhou University), for data analysis and literature research. None of these opacities on chest CT, and 1 also had subsegmental areas of con- persons received any compensation for their contributions. solidation and fibrosis. All the symptomatic patients had in- 1. Paules CI, Marston HD, Fauci AS. Coronavirus infections—more than just the creased C-reactive protein levels and reduced lymphocyte common cold. JAMA. Published online January 23, 2020. doi:10.1001/jama. counts (Table). 2020.0757 2. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of Discussion | A familial cluster of 5 patients with COVID-19 novel coronavirus-infected pneumonia. N Engl J Med. Published online January 29, 2020. doi:10.1056/NEJMoa2001316 pneumonia in Anyang, China, had contact before their symp- tom onset with an asymptomatic family member who had 3. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. traveled from the epidemic center of Wuhan. The sequence Published online February 7, 2020. doi:10.1001/jama.2020.1585 of events suggests that the coronavirus may have been trans- 4. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of 2019 novel coronavirus mitted by the asymptomatic carrier. The incubation period infection in China. medRxiv. Published February 9, 2020. Accessed February 18, for patient 1 was 19 days, which is long but within the 2020. https://www.medrxiv.org/content/10.1101/2020.02.06.20020974v1 reported range of 0 to 24 days.4 Her first RT-PCR result was 5. Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus negative; false-negative results have been observed related to (2019-nCoV) by real-time RT-PCR. Euro Surveill. Published online January 23, 2020. doi:10.2807/1560-7917.ES.2020.25.3.2000045 the quality of the kit, the collected sample, or performance of 6. Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated the test. RT-PCR has been widely deployed in diagnostic with the 2019 novel coronavirus indicating person-to-person transmission: virology and has yielded few false-positive outcomes.5 Thus, a study of a family cluster. Lancet. 2020;395(10223):514-523. doi:10.1016/ her second RT-PCR result was unlikely to have been a false- S0140-6736(20)30154-9 positive and was used to define infection with the coronavi- rus that causes COVID-19. Association Between Supervision One previous study reported an asymptomatic 10-year- and Perceived Overnight Supervision Adequacy old boy with COVID-19 infection, but he had abnormalities on Among Internal Medicine Residents in the US chest CT.6 If the findings in this report of presumed transmis- Overnight supervision of internal medicine residents has tra- sion by an asymptomatic carrier are replicated, the preven- ditionally been indirect1 and provided by a outside tion of COVID-19 infection would prove challenging. The the hospital. During the past 15 years, the complexity and mechanism by which asymptomatic carriers could acquire and volume of overnight inpatient medical services have transmit the coronavirus that causes COVID-19 requires fur- increased.2,3 This, coupled with data that increased resident ther study. supervision is associated with improved ,4 has led many teaching to employ hospitalists in-house Yan Bai, MD overnight ().1,5 Lingsheng Yao, MD Little is known about the national landscape of resident Tao Wei, MD overnight supervision, including how commonly internal medi- Fei Tian, MD cine residency programs use nocturnists and how they affect Dong-Yan Jin, PhD residents’ supervision. We tested whether residents in pro- Lijuan Chen, PhD grams with nocturnists perceived nighttime supervision dif- Meiyun Wang, MD, PhD ferently than those in programs without nocturnists.

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Table 1. Characteristics of Respondentsa

No. (%) Overall With nocturnists Without nocturnists Characteristic (N = 20 744) (n = 10 902) (n = 9842) P valueb Sex c Male 11 742 (56.6) 6288 (57.7) 5454 (55.4) a .82 Respondents not affiliated with US Female 9002 (43.4) 4614 (42.3) 4388 (44.2) residency programs and those who Postgraduate year opted out of allowing access to their data for analysis were excluded. 1 7017 (33.8) 4242 (38.9) 2775 (28.2) .06 Data from 20 744 respondents 2 7222 (34.8) 3612 (33.1) 3610 (36.7) .44 were analyzed. b 2 3 6505 (31.4) 3048 (28.0) 3457 (35.1) .09 Calculated using the Pearson χ1 Type of program bivariate test and compares the group with nocturnists vs the group Categorical 17 868 (86.1) 9459 (86.8) 8409 (85.4) .89 without nocturnists (the α level 1410 (6.8) 692 (6.4) 718 (7.3) .92d was .05). Medicine-pediatrics 957 (4.6) 440 (4.0) 517 (5.3) .97d c Nationally, 58% of internal medicine residents are male and 49.4% are Preliminary 311 (1.5) 200 (1.8) 111 (1.1) .34d graduates of US medical schools.6 Other (not specified) 198 (1.0) 111 (1.0) 87 (0.9) .97d d Calculated using the adjusted Wald Medical school χ2 (bivariate test) and compares the US medical graduate 12 870 (62.0)c 6467 (59.3) 6403 (65.1) group with nocturnists vs the group .22 without nocturnists (the α level Non-US medical graduate 7874 (38.0) 4435 (40.7) 3439 (34.9) was .05).

Methods | The American College of Physicians Internal Medi- dents in categorical programs, with no differences between re- cine In-Training Examination (IM-ITE) includes a voluntary sur- spondents with nocturnists and without nocturnists. vey. The 2017 survey asked residents, “How often do you re- Overall, 51.4% of respondents reported that their super- ceive adequate supervision to ensure patient safety when you vision at night was “always” adequate to ensure patient safety, are working overnight?” using a 5-point Likert scale (re- 31.9% responded “most of the time,”10.6% responded “some- sponses of “always,”“most of the time,”“sometimes,”“rarely,” times,”4.4% responded “rarely,”and 1.7% responded “never” or “never”). Presence or absence of nocturnists was deter- (Table 2). Fifty-three percent of residents reported having a noc- mined by a yes or no response to “Does your internal medi- turnist. Significantly more residents who reported having a cine residency program have an attending physician who stays nocturnist reported “always” receiving adequate supervi- in the hospital overnight and is responsible for directly super- sion to ensure patient safety overnight compared with resi- vising internal medicine residents providing care on medi- dents who reported not having a nocturnist (61.3% vs 40.5%, cine wards?” respectively; P < .001). The results for residents having a noc- This analysis was confined to residents in US programs. Be- turnist vs not having a nocturnist were statistically signifi- cause patient safety is a minimum standard of supervision, we cant when “always” vs all other responses were compared and used Pearson χ2 or adjusted Wald χ2 statistics to compare the when all response categories were compared. Results were “always” response for receiving adequate supervision with all similar by postgraduate year (Table 2). other responses in respondents with and without noc- turnists, with an α level of P ≤ .05. We also performed group- Discussion | Fifty-one percent of internal medicine residents re- based hypothesis testing among all responses using the Pear- ported that their overnight supervision was always adequate son χ2 statistic. Because senior residents may supervise their to ensure patient safety. When nocturnists were present, more juniors, we conducted analyses overall and stratified by post- residents (61%) reported always receiving adequate supervi- graduate year using the adjusted Wald χ2 statistic and the Ken- sion than when they were not (40%). However, a substantial

dall τb correlation coefficient interacting presence or absence percentage did not report always receiving adequate supervi- of nocturnist and postgraduate year with all responses and an sion despite having a nocturnist, possibly reflecting variabil- α level of P ≤ .01. The data analysis was conducted in Stata SE ity in nocturnist job descriptions across institutions. Some noc- version 14.2 (StataCorp). turnists provide care independently while being available for This study was declared exempt by the George Washing- indirect supervision, whereas others primarily provide direct ton University institutional review board. supervision.1,5 Strengths of this study include its large size, high re- Results | Of 24 620 internal medicine residents in US programs sponse rate, and capture of a substantial majority of US inter- who completed the IM-ITE in 2017, 23 553 participated in the nal medicine residents. Limitations include measurement of survey. After excluding 2809 residents who did not allow their perception rather than objective data and cross-sectional sur- data to be used for research purposes, responses from 20 744 vey design. Program characteristics (eg, university-based or internal medicine residents (84% response rate) were ana- community-based) were not collected and confounding due lyzed (Table 1). Fifty-six percent were male and 86.1% were resi- to program-level variability is possible. These data do not

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Table 2. Perception of Adequacy of Supervision to Ensure Patient Safety Overnight

How often do you receive adequate supervision to ensure patient safety when you are working overnight? Total Alwaysa Most of the time Sometimes Rarely Never All respondentsa 20 744 10 662 (51.4) 6614 (31.9) 2201 (10.6) 920 (4.4) 347 (1.7) With nocturnist 10 902 6678 (61.3) 3337 (30.6) 735 (6.7) 127 (1.2) 25 (0.2) Without nocturnist 9842 3984 (40.5) 3277 (33.3) 1466 (14.9) 793 (8.1) 322 (3.3) PGY-3b With nocturnist 3048 1911 (62.7) 894 (29.3) 199 (6.5) 35 (1.2) 9 (0.3) Without nocturnist 3457 1431 (41.4) 1125 (32.5) 471 (13.6) 311 (9.0) 119 (3.4) PGY-2 With nocturnist 3612 2152 (59.6) 1151 (31.9) 253 (7.0) 49 (1.4) 7 (0.2) Without nocturnist 3610 1375 (38.1) 1236 (34.2) 590 (16.3) 292 (8.1) 117 (3.2) PGY-1 With nocturnist 4242 2615 (61.7) 1292 (30.5) 283 (6.7) 43 (1.0) 9 (0.2) Without nocturnist 2775 1178 (42.5) 916 (33.0) 405 (14.6) 190 (6.9) 86 (3.1)

a 2 2 b The Pearson χ1 or adjusted Wald χ1 bivariate test statistics were used to To ensure no confounding of the results based on postgraduate year (PGY) or compare the group with nocturnists vs the group without nocturnists for a the presence or absence of a nocturnist, all response options were tested for dichotomous comparison between the “always” response and the 4 other independence using the adjusted Wald χ2 test stratified by PGY level (the α

response options combined. The α level was .05; P < .001 for all group-based level was .05; P < .001) and the Kendall τb correlation coefficient, −0.0353 comparisons. (the α level was .01; P < .001).

account for other factors that may affect perceived supervi- 1. Farnan JM, Burger A, Boonyasai RT, et al; SGIM Housestaff Oversight sion, including safety culture and other personnel. Subcommittee. Survey of overnight academic hospitalist supervision of trainees. JHospMed. 2012;7(7):521-523. doi:10.1002/jhm.1961 Hospitals should assess adequacy of their nighttime su- 2. Hundert SA, White AA, Reilly DF. Number of general medicine hospital pervision of residents to ensure patient safety. Best practices admissions performed by internal medicine residents before and after the 2011 for roles of nocturnists merit further study. duty-hour regulations. South Med J. 2015;108(8):476-481. 3. Clark AV, LoPresti CM, Smith TI. Trends in inpatient admission comorbidity Jillian S. Catalanotti, MD, MPH and electronic health data: implications for resident workload intensity. JHosp Alec B. O’Connor, MD, MPH Med. 2018;13(8):570-572. doi:10.12788/jhm.2954 Michael Kisielewski, MA 4. Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape L. Implementing the 2009 Institute of Medicine recommendations on resident physician work Davoren A. Chick, MD hours, supervision, and safety. Nat Sci Sleep. 2011;3:47-85. Kathlyn E. Fletcher, MD, MA 5. Trowbridge RL, Almeder L, Jacquet M, Fairfield KM. The effect of overnight in-house attending coverage on perceptions of care and education on a general Author Affiliations: Department of Medicine, George Washington University, medical service. J Grad Med Educ. 2010;2(1):53-56. doi:10.4300/JGME-D-09- Washington, DC (Catalanotti); Department of Medicine, University of Rochester 00056.1 School of Medicine and Dentistry, Rochester, New York (O’Connor); Alliance for 6. Brotherton SE, Etzel SI. Graduate medical education, 2017-2018. JAMA. 2018; Academic Internal Medicine, Alexandria, Virginia (Kisielewski); American 320(10):1051-1070. doi:10.1001/jama.2018.10650 College of Physicians, Philadelphia, Pennsylvania (Chick); Department of Medicine, Medical College of Wisconsin, Milwaukee (Fletcher). Accepted for Publication: January 22, 2020. COMMENT & RESPONSE Corresponding Author: Jillian S. Catalanotti, MD, MPH, Medical Faculty Associates, Division of General Internal Medicine, George Washington Suicides Among Opioid Overdose Deaths University, 2150 Pennsylvania Ave NW, Ste 5-416, Washington, DC 20037 1 ([email protected]). To the Editor Dr Olfson and colleagues examined trends in Author Contributions: Mr Kisielewski had full access to all of the data in the the rates of opioid-related mortality, stratified by intention- study and takes responsibility for the integrity of the data and the accuracy of ality. Concerns about whether a significant proportion of the data analysis. opioid overdose suicides have been misclassified, and Concept and design: Catalanotti, O’Connor. therefore that the suicide component of the opioid epi- Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Catalanotti, O’Connor, Kisielewski, Fletcher. demic is underestimated, cannot be answered with death Critical revision of the manuscript for important intellectual content: O’Connor, certificate data. Kisielewski, Chick, Fletcher. The Centers for Control and Prevention has been Statistical analysis: Catalanotti, O’Connor, Kisielewski, Fletcher. Administrative, technical, or material support: O’Connor, Kisielewski, Chick. struggling with the difficulty of classifying suicides among Supervision: Chick. overdose deaths for years.2 Several studies have estimated the Conflict of Interest Disclosures: None reported. proportion of misclassification in the National Violent Death Additional Contributions: We thank the American College of Physicians for Reporting System, using suicide notes or advanced statistical including our survey questions on the 2017 Internal Medicine In-Training methods, and have generally agreed on a figure ranging be- Examination resident survey and sharing the data with us for analysis. We also tween 21% and 33%.3,4 Therefore, it seems likely that a sig- thank the Alliance for Academic Medicine and the Association of Program Directors in Internal Medicine survey committee for its assistance with editing nificant number of suicides is hidden within deaths from the the survey questions. opioid epidemic.

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