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Gray A, Hall AM, Chadha J, Leung S, Karnik K, Mangino AA, Ragsdale JW. Do acting interns need residents? A comparison of acting intern experience on hospital medicine resident versus nonresident teams. J Hosp Med 2024. [PMID: 38880931 DOI: 10.1002/jhm.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND The clinical demands for hospitalist groups have grown at academic medical centers, without similar growth of teaching opportunities for faculty. Traditional resident teaching teams are often crowded with learners which can limit acting intern (or subintern) patient encounters. Medical students are often placed on nonresident teaching teams, although there are few studies on learner experience on a nonresident teaching team model. METHODS To address these concerns, we created two nonresident teaching teams composed of one attending and two acting interns. We compared acting intern experience on the nonresident teaching teams to the traditional resident teams to determine if there were significant differences in student experience by reviewing course evaluation data on the two team models. RESULTS Of the 276 students who completed the Internal Medicine Acting Internship from 2019 to 2023, 224 students (81%) completed the course evaluation. The course was highly rated, and the ratings were similar in both models demonstrating that the nonresident teaching team model is an effective option for acting interns. CONCLUSION The nonresident teaching team model can offload crowded teaching teams, add additional acting intern experiences, and add teaching opportunities for hospital medicine attendings.
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Affiliation(s)
- Adam Gray
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Alan M Hall
- Departments of Medicine and Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jagriti Chadha
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Stephanie Leung
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Kelsey Karnik
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, Kentucky, USA
| | - Anthony A Mangino
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, Kentucky, USA
| | - John W Ragsdale
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Westergaard S, Bowden K, Astik GJ, Bowling G, Keniston A, Linker A, Sakumoto M, Schwatka N, Auerbach A, Burden M. Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study. J Hosp Med 2024; 19:486-494. [PMID: 38598752 DOI: 10.1002/jhm.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. OBJECTIVE To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. DESIGN, SETTING AND PARTICIPANTS We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. RESULTS Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. CONCLUSIONS Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.
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Affiliation(s)
- Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kasey Bowden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Greg Bowling
- University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne Linker
- Division of Hospital Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Natalie Schwatka
- Center for Health, Work & Environment, Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Patel V, Keniston A, McBeth L, Arogyaswamy S, Callister C, Dayton K, Mistry N, Mann S, Burden M. Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis. Ann Intern Med 2023; 176:1526-1535. [PMID: 37956429 DOI: 10.7326/m23-1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs). OBJECTIVE To understand the impact of clinical growth on the educational mission for academic hospitalists. DESIGN Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level. SETTING Large AMCs across the United States that experienced clinical growth in the past 5 years. PARTICIPANTS Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs. MEASUREMENTS Themes and subthemes. RESULTS From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams. LIMITATION The study focused on large AMCs. CONCLUSION Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities. PRIMARY FUNDING SOURCE Society of Hospital Medicine Student Scholar Grant.
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Affiliation(s)
- Vishruti Patel
- University of Colorado School of Medicine, Aurora, Colorado (V.P.)
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Lauren McBeth
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Sagarika Arogyaswamy
- California University of Science and Medicine School of Medicine, and Department of Psychiatry, Arrowhead Regional Medical Center, Colton, California (S.A.)
| | - Catherine Callister
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Khooshbu Dayton
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Neelam Mistry
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Sarah Mann
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.K., L.M., C.C., K.D., N.M., S.M., M.B.)
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Murphy EA, White K, Meltzer D, Martin SK. Developing hospitalist educators when teaching time is scarce: The Passport model as a professional development approach. J Hosp Med 2023; 18:860-864. [PMID: 36635876 DOI: 10.1002/jhm.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Elizabeth A Murphy
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Kara White
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - David Meltzer
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Shannon K Martin
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Finn KM, Halvorsen AJ, Chaudhry S, Desai S, Dupras D, Reddy S, Wahi-Gururaj S, Willett L, Zaas AK. Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements. J Gen Intern Med 2020; 35:3205-3209. [PMID: 32869195 PMCID: PMC7661583 DOI: 10.1007/s11606-020-06109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017. OBJECTIVE We sought to determine program directors' (PDs) support for the work hour changes and programmatic response. DESIGN In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions. KEY RESULTS The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%). CONCLUSIONS Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.
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Affiliation(s)
- Kathleen M Finn
- Internal Medicine Residency Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Halvorsen
- Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saima Chaudhry
- Office of Academic Affairs, Memorial Healthcare System, Hollywood, FL, USA
| | - Sanjay Desai
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Denise Dupras
- Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shalini Reddy
- Internal Medicine Residency Program, John H. Stroger Hospital of Cook County Health, Chicago, IL, USA
| | - Sandhya Wahi-Gururaj
- Internal Medicine Residency, Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Lisa Willett
- Tinsley Harrison Internal Medicine Residency, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Aimee K Zaas
- Internal Medicine Residency Program, Duke University School of Medicine, Durham, NC, USA
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Gross CJ, Chiel LE, Gomez AR, Marcus CH, Michelson CD, Winn AS. Defining the Essential Components of a Teaching Service. Pediatrics 2020; 146:peds.2020-0651. [PMID: 32487591 DOI: 10.1542/peds.2020-0651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A large portion of residency education occurs in inpatient teaching services without widely accepted consensus regarding the essential components that constitute a teaching service. We sought to generate consensus around this topic, with the goal of developing criteria programs that can be used when creating, redesigning, or evaluating teaching services. METHODS A list of potential components of teaching services was developed from a literature search, interviews, and focus groups. Eighteen pediatric medical education experts participated in a modified Delphi method, responding to a series of surveys rating the importance of the proposed components. Each iterative survey was amended on the basis of the results of the previous survey. A final survey evaluating the (1) effort and (2) impact of implementing components that had reached consensus as recommended was distributed. RESULTS Each survey had 100% panelist response. Five survey rounds were conducted. Fourteen attending physician characteristics and 7 system characteristics reached consensus as essential components of a teaching service. An additional 25 items reached consensus as recommended. When evaluating the effort and impact of these items, the implementation of attending characteristics was perceived as requiring less effort than system characteristics but as having similar impact. CONCLUSIONS Consensus on the essential and recommended components of a resident teaching service was achieved by using the modified Delphi method. Although the items that reached consensus as essential are similar to those proposed by the Accreditation Council for Graduate Medical Education, those that reached consensus as recommended are less commonly discussed and should be strongly considered by institutions.
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Affiliation(s)
- Caroline J Gross
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and .,Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Laura E Chiel
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Amanda R Gomez
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Carolyn H Marcus
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Catherine D Michelson
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Ariel S Winn
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
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O'Donnell CM, Stern M, Leong T, Molitch-Hou E, Mitchell B. Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay. Am J Med Qual 2018; 34:553-560. [PMID: 30569734 DOI: 10.1177/1062860618818355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.
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8
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Repp AB, Bartsch JC, Pasanen ME. What the "Nonteaching" Service Can Teach Us. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:41-44. [PMID: 28746070 DOI: 10.1097/acm.0000000000001833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
"Teaching" services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team, led by a faculty physician. "Nonteaching" services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services have grown in number and size at academic medical centers (AMCs) in response to regulatory requirements, operational demands, and efforts to improve clinical education. The allocation of patients to teaching and nonteaching services is frequently based on perceived teaching value of hospitalized patients, which can potentially lead to a number of unintended consequences for medical education, professional satisfaction, and patient care. Through a series of four lessons, the authors describe how the structure of nonteaching services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of AMCs. Anticipating the continued expansion and evolution of nonteaching services, the authors propose seven design principles for nonteaching services to ensure robust education for students and resident physicians, advance quality of care, and enhance attending physician and patient experience.
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Affiliation(s)
- Allen B Repp
- A.B. Repp is associate professor and vice chair for quality, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont; ORCID: http://orcid.org/0000-0001-7513-532X. J.C. Bartsch is assistant professor, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont. M.E. Pasanen is associate professor, internal medicine residency program director, and chief, Division of Hospital Medicine, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
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Abstract
BACKGROUND Hospitalists, or physicians specializing in hospital-based practice, have grown significantly since they were first introduced in the United States in the mid-1990s. Prior studies on the impact of hospitalists have focused on costs and length of stay. However, there is dearth of research exploring the relationship between hospitals' use of hospitalists and organizational performance. PURPOSE Using a national longitudinal sample of acute care hospitals operating in the United States between 2007 and 2014, this study explores the impact of hospitalists staffing intensity on hospitals' financial performance. METHODOLOGY Data sources for this study included the American Hospital Association Annual Survey, the Area Health Resources File, and the Centers for Medicare & Medicaid Services' costs reports and Case Mix Index files. Data were analyzed using a panel design with facility and year fixed effects regression. RESULTS Results showed that hospitals that switched from not using hospitalists to using a high hospitalist staffing intensity had both increased patient revenues and higher operating costs per adjusted patient day. However, the higher operating costs from high hospitalist staffing intensity were offset by increased patient revenues, resulting in a marginally significant increase in operating profitability (p < .1). PRACTICE IMPLICATIONS These findings suggest that the rise in the use of hospitalists may be fueled by financial incentives such as increased revenues and profitability in addition to other drivers of adoption.
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Roberts DL, Labonte HR, Cheng MR, Chang YHH. Resident and hospitalist perspectives on the "great teaching case": Correlation with actual patient assignment decisions. J Hosp Med 2014; 9:508-14. [PMID: 24801638 DOI: 10.1002/jhm.2206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND With the advent of limits to resident duty hours and the size of teaching services, many academic institutions have introduced nonteaching services, often triaging perceived better teaching cases to the resident services. OBJECTIVE To compare resident versus faculty perceptions of ideal cases for teaching services and compare these perceptions with actual triage decisions made by faculty who assigned patients to either teaching or nonteaching services. DESIGN Residents and hospitalist faculty were surveyed about their perceptions of ideal and actual teaching admissions, first with qualitative, open-ended questions and then with quantitative, specific questions generated from responses to the first survey. Characteristics of patients admitted to teaching and nonteaching services were analyzed retrospectively and compared with resident and faculty perceptions. RESULTS Residents and faculty agreed that rare cases, patients with unique physical findings, and a variety of pathology were ideal for teaching services and that social admissions, benefactors, and patients with chronic or functional pain were not. Residents believed that traditional ("bread and butter") medicine cases were under-represented on the teaching services. Although residents perceived that they received a disproportionate number of older patients, outside transfers, patients with chronic pain, and patients with cancer, the only statistically significant difference was in patient age, with the teaching service actually receiving younger patients (66.7 vs 69.3 years; P=0.008). CONCLUSIONS Residents and faculty have similar views about ideal teaching cases, but a triage system based on perceived educational merit creates the possibility of resident misperceptions about their case mix, even if patients are distributed relatively equitably.
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Affiliation(s)
- Daniel L Roberts
- Division of Hospital Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona
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11
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Gotlib Conn L, Reeves S, Dainty K, Kenaszchuk C, Zwarenstein M. Interprofessional communication with hospitalist and consultant physicians in general internal medicine: a qualitative study. BMC Health Serv Res 2012. [PMID: 23198855 PMCID: PMC3520700 DOI: 10.1186/1472-6963-12-437] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Studies in General Internal Medicine [GIM] settings have shown that optimizing interprofessional communication is important, yet complex and challenging. While the physician is integral to interprofessional work in GIM there are often communication barriers in place that impact perceptions and experiences with the quality and quantity of their communication with other team members. This study aims to understand how team members’ perceptions and experiences with the communication styles and strategies of either hospitalist or consultant physicians in their units influence the quality and effectiveness of interprofessional relations and work. Methods A multiple case study methodology was used. Thirty-one semi-structured interviews were conducted with physicians, nurses and other health care providers [e.g. physiotherapist, social worker, etc.] working across 5 interprofessional GIM programs. Questions explored participants’ experiences with communication with all other health care providers in their units, probing for barriers and enablers to effective interprofessional work, as well as the use of communication tools or strategies. Observations in GIM wards were also conducted. Results Three main themes emerged from the data: [1] availability for interprofessional communication, [2] relationship-building for effective communication, and [3] physician vs. team-based approaches. Findings suggest a significant contrast in participants’ experiences with the quantity and quality of interprofessional relationships and work when comparing the communication styles and strategies of hospitalist and consultant physicians. Hospitalist staffed GIM units were believed to have more frequent and higher caliber interprofessional communication and collaboration, resulting in more positive experiences among all health care providers in a given unit. Conclusions This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes.
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Affiliation(s)
- Lesley Gotlib Conn
- Department of Surgery, St, Michael's Hospital, 30 Bond St., Toronto, ON M5B 1W8, Canada.
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12
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Schaefer EW, Williams MV, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med 2012; 7:489-96. [PMID: 22290766 DOI: 10.1002/jhm.1903] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 11/05/2011] [Accepted: 11/20/2011] [Indexed: 11/10/2022]
Abstract
Shift work is necessary for hospitalists to provide on-site 24-hour patient care. Like all shift workers, hospitalists working beyond daylight hours are subject to a misalignment between work obligations and the endogenous circadian system, which regulates sleep and alertness patterns. With chronic misalignment, sleep loss accumulates and can lead to shift work disorder or other chronic medical conditions. Hospitalists suffering from sleep deprivation also risk increased rates of medical errors. By realigning work and circadian schedules, a process called circadian adaptation, hospitalists can limit fatigue and potentially improve safety. Adaptation strategies include improving sleep hygiene before work, caffeine use at the start of the night shift, bright light exposure and planned naps during the shift, and short-term use of a mild hypnotic after night work. If these attempts fail and chronic fatigue persists, then a diagnosis of shift work disorder should be considered, which can be treated with stronger pharmacotherapy. Night float scheduling strategies may also help to limit chronic sleep loss. More research is urgently needed regarding the sleep patterns and job performance of hospitalists working at night to improve scheduling decisions and patient safety.
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Affiliation(s)
- Eric W Schaefer
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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13
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Chuang C. Transition of patients with COPD across different care settings: challenges and opportunities for hospitalists. Hosp Pract (1995) 2012; 40:176-85. [PMID: 22406893 DOI: 10.3810/hp.2012.02.958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hospitalists play an important role in treating current and preventing future acute exacerbations of chronic obstructive pulmonary disease (AECOPD), which are associated with high rates of medical resource use and morbidity. Comprehensive admission screening and diagnostic tests are important in enabling hospitalists to reliably identify patients with AECOPD, the severity of the episode, and related issues that may prolong patients' hospital length of stay. Recurring exacerbations, especially those that require repeated acute care, can reduce physical activity and accelerate pulmonary decline and risk of death. Recommended pharmacotherapies for AECOPD should include short-acting bronchodilators, systemic corticosteroids, and appropriate antibiotics in cases of suspected bacterial infection. Patients with demonstrable hypoxemia or respiratory failure may benefit from oxygen and/or ventilatory support. Long-term disease management with the goal of preventing future exacerbations should include ongoing emphasis toward smoking cessation and up-to-date vaccination, in addition to prescribing maintenance pharmacotherapies in accordance with respiratory treatment guidelines. Additional benefits may be derived from nonpharmacologic therapies, such as pulmonary rehabilitation, weight-loss recommendations, and treatment of obstructive sleep dyspnea when present. Effective communication among members of the inpatient and outpatient health care teams, the patient, and his or her caregivers is an important aspect of care transitions. Hospital discharge summaries should be transmitted to the patient's primary care physician and be readily available at the first follow-up visit. Discharge coaches and other allied health care providers can aid hospitalists in reinforcing self-management skills and patient education, and in emphasizing the importance of follow-up visits. Recent findings suggest that health and cost benefits are associated with improved COPD management. This article focuses on the pivotal role of the hospitalist in promoting and facilitating the steps toward improving quality outcomes and transitions of care for patients with COPD.
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Affiliation(s)
- Chan Chuang
- HealthCare Partners Medical Group, Torrance, CA 90502, USA.
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14
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The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med 2011; 39:2540-9. [PMID: 21705890 DOI: 10.1097/ccm.0b013e318225776f] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units. PARTICIPANTS A multidisciplinary group of professionals with expertise in critical care education and clinical practice. DATA SOURCES AND SYNTHESIS Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report. MAIN RESULTS The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts. CONCLUSIONS Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.
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Singh S, Fletcher KE, Schapira MM, Conti M, Tarima S, Biblo LA, Whittle J. A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model. J Hosp Med 2011; 6:122-30. [PMID: 21387547 DOI: 10.1002/jhm.826] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Residency reform in the form of work hour restrictions has forced academic medical centers to develop alternate models of care to provide inpatient care. One such model is the use of physician assistants (PAs) with hospitalists. However, these models of care have not been widely evaluated. OBJECTIVE To compare the outcomes of inpatient care provided by a hospitalist-PA (H-PA) model with the traditional resident based model. DESIGN, SETTING AND PATIENTS We conducted a retrospective cohort study of 9681 general medical (GM) hospitalizations between January 2005 and December 2006 using a hospital administrative database. We used multivariable mixed models to adjust for a wide variety of potential confounders and account for multiple patient visits to the hospital to compare the outcomes of 2171 hospitalizations to H-PA teams with those of 7510 hospitalizations to resident teams (RES). MEASUREMENTS Length of stay (LOS), charges, readmission within 7, 14, and 30 days and inpatient mortality. RESULTS Inpatient care provided by H-PA teams was associated with a 6.73% longer LOS (P = 0.005) but charges, risk of readmission at 7, 14, and 30 days and inpatient mortality were similar to resident-based teams. The increase in LOS was dependent on the time of admission of the patients. CONCLUSIONS H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses.
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Affiliation(s)
- Siddhartha Singh
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Sehgal NL, Sharpe BA, Auerbach AA, Wachter RM. Investing in the future: building an academic hospitalist faculty development program. J Hosp Med 2011; 6:161-6. [PMID: 21387552 DOI: 10.1002/jhm.845] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills. OBJECTIVE To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty. INTERVENTION We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress. RESULTS Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output. CONCLUSION Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.
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Affiliation(s)
- Niraj L Sehgal
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California 94143, USA.
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Kim CS, Lovejoy W, Paulsen M, Chang R, Flanders SA. Hospitalist time usage and cyclicality: opportunities to improve efficiency. J Hosp Med 2010; 5:329-34. [PMID: 20803670 DOI: 10.1002/jhm.613] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists' work flow. DESIGN We performed a time-motion study of hospitalists carrying the admission pager throughout the 3 types of shifts we have at our hospital (day shift, swing shift, and night shift). SETTING Tertiary academic medical center in the Midwest. RESULTS Hospitalists spend about 15% of their time on direct patient care, and two-thirds of their time on indirect patient care. Of the indirect activities, communication and documentation dominate. Travel demands make up over 7% of a hospitalists' time. There are spikes in indirect patient care, followed closely by spikes in direct patient care, at shift changes. CONCLUSIONS At our AMC, indirect patient care activities accounted for the majority of the admitting hospitalists' time spent in the hospital, with documentation and communication dominating this time. Travel takes a significant fraction of hospitalists' time. There is also a cyclical nature to activities performed throughout the day, which can cause patient delays and impose variability on support services. There is a need for both service-specific and systemic improvements for AMCs to efficiently manage further growth in their inpatient volume.
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Affiliation(s)
- Christopher S Kim
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109-5376, USA
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Kneeland PP, Kneeland C, Wachter RM. Bleeding talent: a lesson from industry on embracing physician workforce challenges. J Hosp Med 2010; 5:306-10. [PMID: 20533581 DOI: 10.1002/jhm.594] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Shortages of both generalist and specialist physicians are intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures, including an aging population, the retirement of thousands of baby-boomer physicians, the growth of nonpractice opportunities for MDs, and physician demands for greater work-life balance. This work posits that the medical profession might benefit from recognizing how progressive nonmedical companies systematically approach similar "talent shortages" through a recruiting and retention strategy called "talent facilitation." It highlights the 4 actions of talent facilitation (attract, engage, develop, and retain) and provides examples of how each action might be utilized to address medicine's recruitment and retention challenges. Although other policy maneuvers are needed to address overall physician workforce shortages (such as the planned opening of more medical schools and changes in the payment system to promote primary care), the talent facilitation approach can help individual organizations meet their needs and those of their patients.
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Affiliation(s)
- Patrick P Kneeland
- Department of Medicine, University of California, San Francisco, San Francisco, California 94143-0131, USA.
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Affiliation(s)
- Vikas I Parekh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109-0376, USA.
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Hunt D. Hospitalists' path to becoming the best educators in the hospital. J Hosp Med 2009; 4:463-5. [PMID: 19824091 DOI: 10.1002/jhm.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Porter-Williamson K, Parker M, Babbott S, Steffen P, Stites S. A Model to Improve Value: The Interdisciplinary Palliative Care Services Agreement. J Palliat Med 2009; 12:609-15. [DOI: 10.1089/jpm.2009.0014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - Marilyn Parker
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Stewart Babbott
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Patrick Steffen
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Steven Stites
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
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Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med 2009; 360:2202-15. [PMID: 19458365 DOI: 10.1056/nejmsa0810251] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads. METHODS We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events. RESULTS Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0. CONCLUSIONS Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.
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Affiliation(s)
- Teryl K Nuckols
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, USA.
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