Paging Frequency for Internal Medicine Residents in a Tertiary Care Hospital: A Prospective Observational Mixed Methods Study

Introduction

Paging remains a common mode of communication within hospitals, with physicians receiving a high volume of pages throughout the day. For instance, one study found that internal medicine residents were paged up to 50 times per day, with an average of 22.4 pages. ¹ While hospital pages facilitate the exchange of important clinical information, frequent interruptions have long been recognized to negatively affect both physician care and the physician work environment.^2,3 In addition to disrupting workflow, paging can interfere with resident education and increase overall workload.^4,5 Moreover, a substantial proportion of pages are non-urgent, leading to unnecessary interruptions and contributing to medical errors.^2,6,7

Given that frequent paging may adversely affect resident physicians’ education and training experience, we sought to examine the impact of hospital paging on internal medicine residents during evening and overnight on-call shifts in a large tertiary care centre in Edmonton, Canada. Our objective was to characterize the frequency and urgency of pages received during general internal medicine and subspecialty rotations.

Methods

In this prospective, observational mixed-methods study, Internal medicine residents (N=115) were recruited by email to document pages received while on call at the University of Alberta Hospital, a tertiary care centre in Edmonton, Alberta, Canada between September 2022 and February 2023. Participation was voluntary, and residents received a $35 honorarium to complete the study. All current core internal medicine residents were eligible to volunteer; there were no exclusion criteria. During their evening and overnight on call shifts in general internal medicine, gastroenterology, cardiology, hematology, nephrology, and respirology (during these off hour shifts, residents provide clinical coverage for both specialty specific geographically co-located ward patients, usually 20-25 patients per service, and new consultations from the emergency department or other wards), participants self-categorized and recorded the timing, content category, urgency, and clinical significance of each page using on a call log (See supplemental appendix 1). The number of pages and corresponding percentages (calculated as the number of pages divided by the total number of pages) were calculated.

The page was defined as urgent if the resident felt action was required within one hour and non-urgent if action could be deferred beyond one hour. The pages were categorized as clinically relevant with a change in care (resulting in an action such as ordering tests, adjusting treatment, or require reassessment of the patient), clinically relevant without a change in care (providing pertinent information but not requiring action), or clinically irrelevant (non-urgent, administrative, duplicate, or misdirected pages).

Quantitative paging data for internal medicine subspecialities with a single primary pager were also obtained from the centralized paging system, MediPage, over the span of February 2021 and February 2023. Information on the timing and frequency of pages was extracted directly from MediPage. A one-way analysis of variance (ANOVA) was performed to compare the paging volume per hour across the internal medicine subspecialties, followed by a post-hoc Tukey’s Honestly Significant Difference (HSD) test to identify significant pairwise differences. Statistical analyses were performed using SPSS (version 29.0), with significance defined as p < 0.05.

Ethics approval was obtained from the University of Alberta Health Research Ethics Board.

Results

Between September 2022 and February 2023, 25 residents volunteered to participate and completed call logs, providing data from 70 evening and overnight 15 hour call shifts, with a total of 969 pages. On average, residents received 13.8 pages per shift (defined as working hours from 5:00 pm to 8:00 am). Of all pages, 58.1% were classified as urgent and 38.2% as non-urgent, with residents not defining pages for the remaining 4.7%. Residents reported that 47.8% of pages led to a change in patient care, 32.3% were clinically relevant but did not change patient care, and 17.4% were clinically irrelevant. The majority of pages originated from nurses (75.5%), followed by staff consultants (12.1%), other residents (6.5%), and pharmacists (2.2%). The characteristics of pages are outlined in Table 1.

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Table 1.

Characteristics of Pages Received by Residents During Call Shifts

Characteristics	Count	Percentage (%)
Number of pages	969	100
Interrupted activity
Patient care	620	64.0
Sleep	129	13.3
Nothing	80	8.3
Eating	28	2.9
Charting	27	2.8
Handover	24	2.5
Teaching	21	2.2
Others/Blank	40	4.1
Page sender
Nurses	732	75.5
Staff	144	14.9
Other Residents	44	4.5
Pharmacist	19	2.0
Codes	22	2.3
Others/Unknown	8	0.8
Urgency
Urgent (<1 hour)	563	58.1
Non-Urgent (>1 hour)	370	38.2
Patient Care
Change in patient care	463	47.8
Did not change patient care but relevant	313	32.3
Clinically irrelevant	175	18.1
Content
Patient care	510	52.6
New consults	192	20.0
Order clarification	125	12.9
Test results	85	8.8
Others/Blank	57	5.9

Additional data from MediPage captured 53 538 pages between February 2021 and February 2023, spanning 730 days and 10 950 clinical hours. Paging volumes were significantly higher among residents on Gastroenterology (15.5 pages/shift) and Cardiology (14.1 pages/shift) compared with other internal medicine subspecialties (F = 11.2, p = 7.6 × 10^-8). The average number of pages per hour across internal medicine specialties between February 2021 and February 2023 is shown in Figure 1.OPEN IN VIEWER

Interpretation

On-call internal medicine residents received an average of 13.8 pages per shift, of which 38.2% were classified as non-urgent and 17.4% as clinically irrelevant. Over half of these pages resulted in interruptions to patient care, highlighting the impact of frequent paging on workflow, focus, and overall efficiency during call shifts. Such interruptions have been shown to increase cognitive load, contribute to inefficiencies in patient care, and heighten the risk of medical errors.^8,9 Previous studies have reported that only 5–30% of pages are appropriate or require an immediate response.^7,10,11 Many interruptions could instead be managed through less intrusive systems, such as text-based communication or deferred task lists for the daytime, which may allow providers to prioritize urgent issues and minimize unnecessary disruptions. At our tertiary care centre, alphanumeric pages are routed through a centralized switchboard, with no option for text messaging, thereby necessitating an immediate response to every page. These findings underscore the need for local guidelines to optimize the use of alphanumeric paging and promote efficient, purposeful communication among inpatient health care teams. Training initiatives focused on best practices for pager communication may further enhance workflow and support safer, more effective patient care.

We additionally examined the timing of pages received by residents via the centralized paging platform and identified distinct peaks in paging frequency between 21:00–23:00 and 05:00–08:00, reaching up to 1.7 pages per hour. These peaks coincide with nursing shift change times, suggesting that communication handovers may contribute to increased paging activity. This finding highlights a potential opportunity to streamline processes during shift transitions – either through a dedicated time for a multidisciplinary meeting or to consolidate pages - to reduce redundancy and improve communication efficiency. Furthermore, gastroenterology and cardiology services experienced higher paging volumes compared to other specialties (respirology, nephrology, general internal medicine). Within the context of the collaborative night-pool model adapted in the internal medicine program, where four residents each oversee a subspecialty service, these differences emphasize the importance of cross-coverage support and workload redistribution to ensure equitable workload and optimize resident efficiency. ¹²

One of the limitations of this study is the subjective nature of residents’ self-reported assessment of urgency and clinical relevance of pages. Further, resident participation was voluntary, which could result in selection bias. To address this, we used centralized paging data to corroborate paging frequency. However, this analysis was restricted to specialties with dedicated on-call numeric pagers, excluding data from personal pagers. As a result, the true paging volume may have been underestimated. Conversely, some pages could have been duplicated if not responded to immediately, which was not accounted for in this analysis.

Future research should identify alternative communication strategies for on-call resident physicians and relate findings to measures of physician wellness. With the wider implementation of universal hospital electronic medical records, further studies could examine how these platforms impact paging volumes and overall hospital work-flow. Additionally, future work could investigate how paging volumes vary by site, weekday, season, and level of training, and relate these findings to resident burnout and well-being.

Conclusion

Although paging remains a fundamental method for communicating urgent clinical information, our findings indicate that more than one-third of pages received by on-call internal medicine residents are non-urgent, and fewer than half lead to a change in patient management. Furthermore, paging interrupts residents during critical on-call duties, including direct patient care, in more than half of instances. Future efforts should evaluate alternative communication modalities, such as encrypted alphanumeric paging or secure direct messaging, to minimize unnecessary interruptions and enhance both patient care and physician well-being.

Supplemental Material