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IM programs reported formal (92.9%, 247\/266) or informal (6.4%, 17\/266) backup systems. Most (64.3%, 169\/263) felt use of the backup system had increased since the COVID-19 pandemic. Over 90% of programs listed acute illness, family emergencies, fatigue\/impairment, and bereavement as reasons for backup coverage. Most programs (&gt;\u200990%) provided coverage for absences from the inpatient ward, ICU services, and\/or night float; however, 40.2% covered absences in primary care clinics. Most programs (87.4%, 229\/262) had residents on backup during other clinical\/educational rotations. Fewer than 20% of programs compensated residents for backup, namely time off and decreased likelihood of pull for future coverage. Only 15.4% (8\/52) of programs provided monetary compensation. For long-term absences, 82.7% (220\/266) of programs coordinated trades and 35.7% (99\/266) used backup. Six themes characterized challenges of backup coverage: healthcare resources, call-ins culture change, balancing equity, patient care versus education, administrative burden, wellness\/ burnout focus, parental\/extended leave requirements. IM PDs expressed competing demands with backup systems.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>While backup systems are nearly ubiquitous in IM residency programs, PDs report significant strains in these systems including possible cultural shift in illness definition, workload imbalances post-COVID, and prioritization of inpatient coverage over primary care. System-level changes are needed to improve backup coverage systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11606-026-10486-4","type":"journal-article","created":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T17:58:36Z","timestamp":1779127116000},"page":"3203-3212","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["\u201cWho\u2019s on Backup?\u201d\u2014Exploring Internal Medicine Residency Backup Coverage Systems: Findings from a National Survey"],"prefix":"10.1007","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8915-6420","authenticated-orcid":false,"given":"Emily S.","family":"Wang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joel C.","family":"Boggan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Leasure","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lydia","family":"Redway","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica N.","family":"Johnson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia F.","family":"Kao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven J.","family":"Durning","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Rasnake","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,18]]},"reference":[{"issue":"18","key":"10486_CR1","doi-asserted-by":"publisher","first-page":"1377","DOI":"10.1001\/archinternmed.2012.3199","volume":"172","author":"TD Shanafelt","year":"2012","unstructured":"Shanafelt TD, Boone S, Tan L, et al. 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