Effect of hospitalist attending physicians on trainee educational experiences: a systematic review

Education Research: Educational Outcomes Associated With the Introduction of a Neurohospitalist Program

Background and Objectives

As the prevalence of the neurohospitalist (NH) practice model grows, understanding its effect on trainee education is imperative. We sought to determine the impact of an academic NH program on neurology resident evaluations of faculty teaching.

Methods

We performed a retrospective study of faculty teaching evaluations before and after the implementation of a full-time NH service. Primary outcomes were neurology resident evaluations of faculty teaching, which were compared in the pre-NH period (August 2010-July 2014) vs the post-NH period (August 2016-July 2018). In a secondary analysis, we used the difference-in-difference approach to analyze the effect of introducing the NH service on resident evaluation of faculty teaching compared with stroke and neurocritical care faculty controls. We performed an additional descriptive analysis of medical student evaluation of faculty teaching and described Residency In-service Training Exam scores and Accreditation Council for Graduate Medical Education (ACGME) resident survey data before and after the intervention.

Results

There were 368 resident and 360 medical student evaluations of faculty teaching during the study period. Compared to the pre-NH period, the post-NH period had significantly higher resident evaluations of faculty teaching in 19 of 27 questions of faculty teaching, across 5 of the 6 ACGME core competencies. Within the competencies of patient care, practice-based learning and improvement, and systems-based practice, the NH teaching faculty were rated significantly higher across all questions. In the difference-in-difference model, resident evaluations of faculty teaching following the implementation of the NH service remained significantly improved compared with controls in teaching evidence-based medicine, teaching diagnostic algorithms, and explaining rationale for clinical decisions. Medical student ratings of faculty teaching were unchanged in the pre-NH and the post-NH period.

Discussion

Neurology residents may benefit from the clinical expertise of NHs and their ability to teach evidence-based practice and role model systems-based practice. Given the central role NHs may play in trainee education, additional focus on both the local and national levels should be dedicated to further developing the teaching skills of NHs.

Teaching and Assessing Bedside Procedures: A Standardized Cross-Disciplinary Framework for Graduate Medical Education

ABSTRACT

Performing bedside procedures requires knowledge, reasoning, physical adeptness, and self-confidence; however, no consensus on a specific, comprehensive strategy for bedside procedure training and implementation is available. Bedside procedure training and credentialing processes across large institutions may vary among departments and specialties, leading to variable standards, creating an environment that lacks consistent accountability, and making quality improvement difficult. In this Scholarly Perspective, the authors describe a standardized bedside procedure training and certification process for graduate medical education with a common, institution-wide educational framework for teaching and assessing the following 7 important bedside procedures: paracentesis; thoracentesis; central venous catheterization; arterial catheterization; bladder catheterization or Foley catheterization; lumbar puncture; and nasogastric, orogastric, and nasoenteric tube placement. The proposed framework is a 4-stage process that includes 1 preparatory learning stage with simulation practice for knowledge acquisition and 3 clinical stages to guide learners from low-risk to high-risk practice and from high to low supervision. The pilot rollout took place at Henry Ford Hospital from December 2020 to July 2021 for 165 residents in the emergency medicine and/or internal medicine residency programs. The program was fully implemented institution-wide in July 2021. Assessment strategies encompass critical action checklists to confirm procedural understanding and a global rating scale to measure performance quality. A major aim of the bedside procedure training and certification was to standardize assessments so that physician trainers from multiple specialties could train, assess, and supervise any participating trainee, regardless of discipline. The authors list considerations revealed from the pilot rollout regarding electronic tracking systems and several benefits and implementation challenges to establishing institution-wide standards. The proposed framework was assembled by a multidisciplinary physician task force and will assist other institutions in adopting best approaches for training physicians in performing these critically important and difficult-to-perform procedures.

Generalists as Clinical Physiologists: Bringing Science Back to the Bedside

BACKGROUND

Few generalists engage in basic science research or feel comfortable teaching physiology at the bedside. This may reflect a lack of understanding or confidence teaching physiologic principles.

AIM

To inspire general internists to relearn and teach physiology in clinical practice.

SETTING

An active biomedical research laboratory.

PARTICIPANTS

We educated 67 faculty participants (4 primary care, 59 hospitalists, and 4 other specialties) from 24 medical centers, representing 17 states.

PROGRAM DESCRIPTION

The 5-day course was structured around re-learning basic physiology principles and developing teaching skills. Participants engaged in hands-on experiments through 4 modules using aquatic species, each paired with a physiology content primer. Participants also developed teaching scripts based on their experiments.

PROGRAM EVALUATION

Post-course surveys revealed that 97% felt confident teaching physiology at the bedside, 100% felt the course enhanced their understanding of the mechanisms of disease, and there was a significant improvement in self-reported teaching ability.

DISCUSSION

An immersive, hands-on faculty development course that integrated physiology with clinical decision-making increased participants' comfort level and self-rated ability to teach and incorporate physiology in their clinical work. We believe faculty development is one potential solution to the growing chasm between clinicians and scientists in general medicine.

Perceptions of Third-year Medical Students of a Non-resident Hospitalist Rotation

Introduction Although medical students in the United States frequently rotate on a non-resident hospitalist team, there is a paucity of literature on their perceptions regarding such rotation. We sought to assess the perceptions of third-year medical students (M3s) regarding a non-resident hospitalist rotation. Methods We conducted a web-based survey of M3s who had previously rotated on a non-resident hospitalist service. We assessed their perceptions regarding patient assignments and complexities, rounding preferences, barriers to learning, and the benefits of the rotation. A descriptive analysis was performed on the responses. Results Out of 49 respondents, 47% preferred carrying a maximum of three patients during rounds and 57% preferred patients with fewer comorbidities. Fifty-one percent preferred rounding on all patients covered by the team as opposed to rounding on their assigned patients only. Despite several perceived benefits of the rotation, students also identified various barriers to learning while rotating in a non-resident hospitalist rotation. Conclusions Our study evaluated the perceptions of M3s regarding the ideal patient load, patient complexities, barriers to learning and various benefits of a non-resident hospitalist rotation. The students' perceptions can potentially be addressed and incorporated to make the non-resident hospitalist rotation more educational for the students.

Whither the Pulmonary Ward Attending? Preserving Subspecialty Exposure in United States Internal Medicine Residency Training

Twenty years ago, the term "hospitalist" was coined at the University of California-San Francisco (San Francisco, CA), heralding a new specialty focused on the care of inpatients. There are now more than 50,000 hospitalists practicing in the United States. At many academic medical centers, hospitalists are largely replacing subspecialists as attendings on the inpatient medicine wards. At University of California-San Francisco, this has been accompanied by declining percentages of residency graduates who enter subspecialty training in internal medicine. The decline in subspecialty medicine interest can be attributed to many factors, including differences in compensation, decreased subspecialist exposure, and a changing research funding landscape. Although there has not been systematic documentation of this trend in pulmonary and critical care medicine, we have noted previously pulmonary and critical care-bound trainees switching to hospital medicine instead. With our broad, multiorgan system perspective, pulmonary and critical care faculty should embrace teaching general medicine. Residency programs have instituted creative solutions to encourage more internal medicine residents to pursue careers in subspecialty medicine. Some solutions include creating rotations that promote more contact with subspecialists and physician-scientists, creating clinician-educator tracks within fellowship programs, and appointing subspecialists to internal medicine residency leadership positions. We need more rigorous research to track the trends and implications of the generalist-specialist balance of inpatient ward teams on resident career choices, and learn what interventions affect those choices.

Pediatric Hospital Medicine: A Proposed New Subspecialty

Over the past 20 years, hospitalists have emerged as a distinct group of pediatric practitioners. In August of 2014, the American Board of Pediatrics (ABP) received a petition to consider recommending that pediatric hospital medicine (PHM) be recognized as a distinct new subspecialty. PHM as a formal subspecialty raises important considerations related to: (1) quality, cost, and access to pediatric health care; (2) current pediatric residency training; (3) the evolving body of knowledge in pediatrics; and (4) the impact on both primary care generalists and existing subspecialists. After a comprehensive and iterative review process, the ABP recommended that the American Board of Medical Specialties approve PHM as a new subspecialty. This article describes the broad array of challenges and certain unique opportunities that were considered by the ABP in supporting PHM as a new pediatric subspecialty.

The future physician

Both hospital-based care and physician training have undergone significant changes within the past decade. Current physician training in the UK is failing to meet the needs of patients, with significant numbers of acute and general medicine posts unfilled. Building on the themes of the 2013 Shape of Training review, we propose a model that places an alternative model of generalist - the 'future hospitalist' - at the centre of patient care and medical training. The reinstatement of the general physician at the heart of hospital care will increase flexibility in both training and workforce planning, and embed active leadership, patient safety and quality improvement in care delivery.

Hospitalists, value and the future

Health systems face increasing pressure to optimise value: providing the best quality care for the lowest possible cost. In the US, changes in modern healthcare, along with early efforts to contain costs, fuelled the growth of a new cadre of inpatient clinicians known as hospitalists. This commentary briefly reviews the history of the hospitalist movement through the lens of healthcare value, examines the evidence for value improvement in the care and training provided by hospitalists, and concludes by exploring both the lessons learned and remaining challenges facing hospitalists. We believe that openness to challenging the status quo was a critical enabler of the US hospitalist's impact on both the healthcare workforce and the American care delivery model. This spirit of re-engineering has far-reaching implications, both in the USA and abroad.

Hospitalist workload and resident evaluations

BACKGROUND

Most academic hospitalists fulfil the role of clinician educator and have many opportunities for the bedside clinical teaching of resident physicians; however, hospitalists are promoted at lower rates than traditional internal medicine faculty staff. The conflict between the demands of clinical productivity and time to teach may be central to understanding the lower rates of academic promotion seen in hospitalists. This investigation explores the relationship between clinical productivity and learner evaluations of hospitalist clinician educators.

METHODS

A retrospective review of clinical productivity and learner evaluations of hospitalists by residents was collected during the 2009-2012 academic years at Southern Illinois University School of Medicine. Correlation analysis between annual work relative value units (wRVUs), patient encounters and duty days with resident evaluations of faculty staff in the Accreditation Council for Graduate Medical Education core competencies was performed.

RESULTS

Forty-one annual data sets, representing 18 individual hospitalists, were analysed. No significant correlations between clinical productivity, in terms of annual work RVUs, patient encounters and duty days, and resident learner evaluation scores was found. This investigation explores the relationship between clinical productivity and learner evaluations of hospitalist clinician educators

DISCUSSION

This study found no significant influence of measures of annual clinical service workload on resident learner evaluations of hospitalist clinical educators. These results are consistent with data reported for emergency medicine doctors and anaesthesiologists. These results may have significant implications for the staffing requirements for academic hospitalists.

Defining the role of the academic neurohospitalist in residency education

OBJECTIVE

We sought to better understand the potential impact of the burgeoning neurohospitalist model of inpatient care on education of neurology residents and to better define possible roles for "neurohospitalists" in residency education.

METHOD

We designed a brief qualitative open-ended survey directed toward academic leaders in neurology and distributed it by e-mail to every academic neurology department in the United States and Canada.

RESULTS

Of 83 respondents, 36 (43%) had an active neurohospitalist program and only 10% felt certain they would not have 1 within the next 5 years. All respondents expected to have residents continue to be involved with inpatient care. The main perceived advantage for resident education associated with neurohospitalists was inpatient care expertise, and the main expected disadvantage was decreased exposure to subspecialty attendings. The majority anticipated positive impact on all Accreditation Council for Graduate Medical Education core competencies predominantly based on neurohospitalists' expertise in the inpatient setting.

CONCLUSION

The majority of academic neurology departments are expected to have a neurohospitalist program within the next 5 years. There are several perceived advantages and disadvantages to such a program for education of neurology residents. In general, the impact of these programs is expected to improve resident education. Regardless of expectations, neurohospitalists will likely play a prominent role in the education of the next generation of neurologists.

An academic hospitalist model to improve healthcare worker communication and learner education: results from a quasi-experimental study at a Veterans Affairs medical center

BACKGROUND

Although hospitalists may improve efficiency and quality of inpatient care, their effect on healthcare-worker communication and education has been less well-studied.

OBJECTIVE

To test various approaches to improving healthcare-worker communication and learner education within the context of a newly designed academic hospital medicine program.

DESIGN

Before-and-after design with concurrent control group.

SETTING

A Midwestern Veterans Affairs medical center.

INTERVENTION

Multimodal systems redesign of 1 of 4 medical teams (Gold team) that included clinical modifications (change in rounding structure, with inclusion of nurses, a Clinical Care Coordinator, and a pharmacist) and educational interventions (providing explicit expectations of learners and providing a reading list for both learners and attending physicians).

MEASUREMENTS

Number of admissions, length of stay, readmissions, house officer and medical student ratings of attendings' teaching, medical student internal medicine National Board of Medical Examiners Subject Examination ("shelf" exam) scores, and clinical staff surveys.

RESULTS

Length of stay was reduced by about 0.3 days on all teams after the initiative began (P = 0.004), with no significant differences between Gold and non-Gold teams. The majority of physicians (83%) and nurses (68%) felt that including nurses during rounds improved healthcare-worker communication; significantly more nurses were satisfied with communication with the Gold team than with the other teams (71% vs 53%; P = 0.02). Gold attendings generally received higher teaching scores compared with non-Gold attendings, and third-year medical students on the Gold team scored significantly higher on the shelf exam compared with non-Gold team students (84 vs 82; P = 0.006).

CONCLUSIONS

Academic hospitalists working within a systems redesign intervention were able to improve healthcare-worker communication and enhance learner education without increasing patient length of stay or readmission rates.

Development of a hospitalist-led-and-directed physical examination curriculum

BACKGROUND

Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades, though specifics on how to address this deficit are lacking.

METHODS

Our institution has made a commitment to improving key physical examination competencies across our general medicine faculty. Development of the Merrin Bedside Teaching Program was guided by a comprehensive needs assessment and based on a learner-centered educational model. First, selected faculty fellows achieve expertise through mentorship with a master clinician. They then develop a bedside teaching curriculum in the selected domain and conclude by delivering the curriculum to peer faculty.

RESULTS

We have developed curricula in examination of the heart, shoulder, knee, and skin. Currently, curricula are being developed in the examination of the lungs, critical care bedside rounds, and motivational interviewing. Curricula are integrated with educational activities of the internal medicine residency and medical school whenever possible.

CONCLUSIONS

A hospitalist-led physical examination curriculum is an innovative way to address deficits in physical exam skills at all levels of training, engenders enthusiasm for skills development from faculty and learners, offers scholarship opportunities to general medicine faculty, encourages collaboration within and between institutions, and augments the education of residents and medical students.

Resident perceptions of autonomy in a complex tertiary care environment improve when supervised by hospitalists

BACKGROUND AND OBJECTIVE

Increasingly, academic hospitals have adopted hospitalist-based systems of inpatient pediatric care. Some studies comparing hospitalists with other attending physicians have suggested trainees are more satisfied with education from hospitalists. However, there are published concerns that the increased presence of hospitalists may reduce residents' autonomy. The objective of the current study was to evaluate pediatric residents' perceptions of their own autonomy after a broad ward restructuring to hospitalist-led teams.

METHODS

We analyzed data from standardized attending evaluations before and after a pediatric ward restructuring at an academic tertiary care hospital. Provision of most inpatient pediatric care changed from subspecialist-led teams to hospitalist-led teams. Numerical scores from evaluations before and after the restructuring were compared quantitatively. Comments from the evaluations were analyzed qualitatively to identify key themes.

RESULTS

Before the restructuring, there were 65 evaluations of 5 hospitalists and 602 evaluations of 32 subspecialists. After the restructuring, there were 188 evaluations of 8 hospitalists. Hospitalists were rated significantly higher on all teaching attributes compared with all attending physicians before the restructuring. The attending role in promoting autonomy was mentioned infrequently and reflected residents' perceived lack of autonomy before the restructuring. The primary theme after the restructuring was autonomy, specifically emphasizing resident leadership and decision-making and the appropriate balance of resident autonomy and supervision.

CONCLUSIONS

Although patient complexity was unchanged, a comparison of numerical ratings and resident comments before and after the restructuring indicates that hospitalists lead teams differently from subspecialists, with more emphasis on resident decision-making and autonomy.

Hospital medicine in the internal medicine clerkship: results from a national survey

BACKGROUND

Hospital medicine is growing rapidly. This changing inpatient work force has had consequences on medical education, with an increasing hospitalist presence in resident and student training. Initially met with apprehension, there is growing literature to suggest that hospitalists are perceived to be more effective clinical teachers than non-hospitalists. However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known.

METHODS

In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey. In June 2010, CDIM surveyed its North American institutional members, which represent 110 of 143 Departments of Medicine in the US and Canada.

RESULTS

Eight-two of 107 departments responded to the survey (77%). Seventy-five (91%) indicated that hospitalists served as teaching attendings at their teaching hospital. In twenty-two (27%) IM departments, 75% to 100% of students rotate with a hospitalist during their IM clerkships. Thirty-three (42%) departments report that students are directly supervised by in-house hospitalists during their nighttime call requirements. Sixty-six (81%) indicated that academic hospitalists hold educational administrative positions. Hospitalists are significantly less likely to have additional clinical commitment as compared to non-hospitalist teaching attendings (16% vs 53%, (χ 21df = 33.1; P < 0.0001).

CONCLUSIONS

Hospitalists are involved in medical student education in the large majority of Departments of Internal Medicine throughout the US and Canada, reflecting the growth of hospital medicine nationally.

The laborist model of obstetric care: we need more evidence

Literature suggesting improved patient outcomes and patient satisfaction with the hospitalist model of inpatient medical care coupled with the desire to improve provider satisfaction led to the introduction of the laborist in obstetrics. This represents a significant change in the way obstetrics has been experienced and practiced from both a patient and provider perspective. The laborist was designed as a plausible model of obstetric care delivery where hospitals employ physicians to provide continuous coverage of labor and delivery units without other competing clinical duties. Anecdotal use of the laborist model in the provision of obstetric care is growing rapidly, despite the lack of research regarding its impact on maternal outcomes, neonatal outcomes, patient and provider satisfaction, and graduate medical education. We provide an overview of both the positive and negative attributes of this model of obstetric care delivery, discuss the current state of research addressing these attributes, and propose a research strategy to improve understanding of the impact of this model of care delivery.

Pediatric hospitalists in medical education: current roles and future directions

As the field of pediatric hospital medicine has evolved, pediatric hospitalists have become increasingly involved in medical student and resident education--providing direct education during clinical rotations, developing novel curricula to meet the demands of the new educational environment, occupying leadership roles in medical education, and more. The literature suggests that hospitalists possess the essential skills for teaching effectively, yet most hospitalists feel that additional training beyond residency is necessary to refine their knowledge and skills in education and in other essential domains. Several pediatric hospital medicine fellowships and continuing medical education activities have been developed in the last decade to meet this growing need. The recent publication of the Pediatric Hospital Medicine Core Competencies will help define the roles and expectations of practicing pediatric hospitalists, and will serve as a framework for future curriculum development in both graduate and continuing medical education.

Pediatric hospital medicine: historical perspectives, inspired future

Pediatric hospital medicine (PHM) is in an accelerated growth phase. Multiple elements have combined to affect the current state of the field. PHM is similar to other geographic specialties such as pediatric emergency medicine and pediatric critical care that deliver general, comprehensive care to patients based on hospital site. Pediatric hospitalists have been molded by changes in medicine, consumer expectations, and training program modifications. The history of PHM dates back for more than 3 decades, when unwitting pediatricians began to focus on delivering care for the hospitalized child. The ensuing years allowed for natural responses to external pressures that resulted in much of the field's initial development. In more recent years, however, pediatric hospitalists have been catalysts for change and driving forces for health care systems' improvements. Simultaneous with this has been the nearly exponential surge of energy focused on targeted initiatives, which have further defined the field and brought attention on a national level. PHM is at a critical but brilliant juncture in development. Further decisions regarding scope and demonstration of competencies are important to make with clarity of purpose. Pediatric hospitalists are advancing child health in the inpatient setting through evidence-based care, research, education, clinical excellence, advocacy, and health care business acumen. With a strong community sense and leadership evident, PHM has a bright future.

The hybrid hospitalist teaching service: an innovative model for individualized learning, patient case-mix, and medical student and resident education

BACKGROUND

Alternative inpatient teams are increasing, but little is known about their impact on patient care and trainee education.

PURPOSE

To evaluate whether a hybrid hospitalist teaching service meets trainee and attending educational, clinical, support, patient-mix, autonomy, and efficiency needs.

METHODS

Post pediatric rotations, team members anonymously completed surveys with Likert-scale and open-ended questions.

RESULTS

In total, 78 of 80 surveys were completed. Trainees rated educational, clinical, support, and case-mix domains highly. Senior residents responded positively for autonomy, education, and opinions of hospitalists, but neutrally on leadership. Attending scores varied for efficiency, teaching, and clinical duties; the service resulted in direct observation and teaching outside of rounds, but poor delineation of roles and expectations impeded clinical task completion, teaching on rounds, and attending meetings.

CONCLUSIONS

This model is a satisfying, well-accepted means of enhancing trainee education and patient care, but roles and expectations must be clearly defined to maximize efficiency and satisfaction.

Clinical instructors' perception of a faculty development programme promoting postgraduate year-1 (PGY1) residents' ACGME six core competencies: a 2-year study

Objective The six core competencies designated by Accreditation Council for Graduate Medical Education (ACGME) are essential for establishing a patient centre holistic medical system. The authors developed a faculty programme to promote the postgraduate year 1 (PGY(1)) resident, ACGME six core competencies. The study aims to assess the clinical instructors' perception, attitudes and subjective impression towards the various sessions of the 'faculty development programme for teaching ACGME competencies.' Methods During 2009 and 2010, 134 clinical instructors participated in the programme to establish their ability to teach and assess PGY(1) residents about ACGME competencies. Results The participants in the faculty development programme reported that the skills most often used while teaching were learnt during circuit and itinerant bedside, physical examination teaching, mini-clinical evaluation exercise (mini-CEX) evaluation demonstration, training workshop and videotapes of 'how to teach ACGME competencies.' Participants reported that circuit bedside teaching and mini-CEX evaluation demonstrations helped them in the interpersonal and communication skills domain, and that the itinerant teaching demonstrations helped them in the professionalism domain, while physical examination teaching and mini-CEX evaluation demonstrations helped them in the patients' care domain. Both the training workshop and videotape session increase familiarity with teaching and assessing skills. Participants who applied the skills learnt from the faculty development programme the most in their teaching and assessment came from internal medicine departments, were young attending physician and had experience as PGY(1) clinical instructors. Conclusions According to the clinical instructors' response, our faculty development programme effectively increased their familiarity with various teaching and assessment skills needed to teach PGY(1) residents and ACGME competencies, and these clinical instructors also then subsequently apply these skills.

The hospitalist movement in general pediatrics

PURPOSE OF REVIEW

The present review focuses on the latest evidence from the past 18 months related to pediatric hospitalist medicine.

RECENT FINDINGS

The number of hospitalists continues to increase despite many programs not being financially self-supporting. Reports in the past have shown decreased length of stay, resource utilization, and costs with the hospitalist model. There are an increasing number of studies examining patient safety, quality initiatives, and communication issues such as 'handoffs' and family-centered rounds. The teaching role continues to broaden in scope and is highly valued by trainees. Pediatric hospitalist fellowship training programs are in an early stage of development. A list of core competencies as a framework for a pediatric hospital medicine curriculum has recently been published and should help to facilitate and standardize training. Recent publications suggest that there is still significant variation in the approach to and management of many common inpatient illnesses.

SUMMARY

In general, there continue to be reports of positive outcomes as a result of the introduction of the hospitalist model in pediatrics. Much of the current literature is geared toward reporting on alternative models of care, inpatient quality and safety initiatives, and hospitalist teaching. What is still somewhat lacking is multicenter collaborative prospective clinical trials for common inpatient general pediatric conditions. The variation reported in the management of common conditions presents an opportunity for improving the quality, safety, resource utilization, and appropriateness of care.