Implications of the hospitalist model for medical students' education

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.

Harnessing the potential of CRISPR-based platforms to advance the field of hospital medicine

INTRODUCTION

Clustered regularly interspaced short palindromic repeats (CRISPR) are segments of nucleic acid that play a role in prokaryotic defense and form the basis of a genome editing technology that allows permanent alteration of genetic material. This methodology, known as CRISPR-Cas9, is poised to revolutionize molecular biology, but no literature yet exists on how these advances will affect hospitalists.

AREAS COVERED

These specialists in inpatient medicine care for a wide variety of hospitalized patients, including those with infectious disease, cancer, cardiovascular disease, autoimmune disease, hematologic disease, and a variety of other conditions that may soon be impacted by advances in gene-modifying technology provided by CRISPR-Cas9. A Literature search was performed using PubMed [1 December 2019-17 April 2020].

EXPERT OPINION

This paper reviews the remarkable diagnostic and therapeutic potential of the CRISPR-Cas9 platform and concludes with a look at ethical issues and technical hurdles pertaining to the implementation of permanent gene modification in the practice of Hospital Medicine.

The rise of hospitalists: an opportunity for infectious diseases investigators

INTRODUCTION

Despite the essential role played by infectious diseases specialists in patient care, public health, cost-containment, and biomedical research, the field has a substantially higher percentage of vacant positions than other medicine sub-specialties. While much has been written about what this disturbing trend means for patient care, comparatively little attention has been focused on the dire implications for clinical research and the development of novel anti-infective therapy. Areas covered: We examine the ways that hospitalists and infectious disease specialists might collaborate to study emerging diagnostic platforms, novel antimicrobial agents, and strengthen antimicrobial stewardship programs to improve the delivery of high-quality health care. Through the use of PubMed, the manuscript reviews existing collaborations as well as those that might develop in the years to come. Expert commentary: In this paper, we propose potential strategies to confront this emerging problem, focusing on novel collaborations with the hospitalist - the specialist in inpatient medicine - to bolster the pipeline of funding for clinical infectious diseases investigators.

Length of attending-student and resident-student interactions in the inpatient medicine clerkship

PHENOMENON: Changes in the medical education milieu have led away from the apprenticeship model resulting in shorter physician-student interactions. Faculty and student feedback suggests that supervisor/student interactions may now be more cursory with increasing numbers of supervisors per student, and shorter duration of interaction. This may affect both education and student assessment.

APPROACH

We compared inpatient attending and resident daily schedules with those of 3rd- and 4th-year medical students rotating on medicine clerkships at Brigham and Women's Hospital during academic years 2009-11 to determine the number of days of overlap. We used evaluation forms to determine the extent of evaluator's self-reported knowledge of the student.

FINDINGS

We correlated the daily schedules of 199 students and 204 resident and 187 attending physicians, which resulted in 558 resident-student pairings and 680 attending-student pairings over 2 years. During a 4-week block, students averaged 3.7 attending physicians (M = 4, range = 2-7), with 49.7% supervised by 4 or more. Attending-student overlap averaged 9 days (M = 9, range = 2-23), though 40% were 7 days or less. Students overlapped with an average 3.4 residents (M = 3, range = 1-6). Resident-student overlap averaged 12 days (M = 11, range = 3-26). There were 824 student assessment forms analyzed. Resident and attending physician supervisors describing knowledge of their student as "good/average" overlapped with students for 14 and 11 days respectively compared to resident and physician supervisors who described their knowledge as "poor" (11 days, p < .01; 6 days, p < .01). Insights: On the inpatient medicine clerkship, students have multiple supervising physicians with wide variability in the period of overlap. This leads to a disrupted apprenticeship model with fragmentation of supervision and concomitant effects on assessment, feedback, role modeling, and clerkship education.

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.

Hospital consultations and jurisdiction over patients: consequences for the medical profession

Advances in biomedical technologies and the increased specialisation of the medical profession have made collaborations among specialty physicians integral to care delivery. As physicians increasingly must share patients, how does this shape the jurisdiction that physicians hold? The sociological literature has extensively documented inter-professional jurisdictional claims and conflicts to maintain the professional power of physicians in relation to allied occupational groups. However, less is known of intra-professional avoidance and resolution of conflict over jurisdiction. This case study considers how jurisdictions are shared, maintained and challenged in a single profession. Drawing from ethnographic and interview data collected from September 2010 to October 2012 on the internal medicine service of a teaching hospital in the USA, I demonstrate the variation in jurisdictional conflicts that emerge between internal medicine and other specialties during the consultation process. Ignoring shared jurisdictions and refusing to accept jurisdiction of patients generate disputes among the principal medical and specialist teams. These disputes ensue due to blurred boundaries dividing the various specialties. To avoid conflicts, internal medicine physicians adopt strategies behind the scenes to facilitate smooth consultations.

Faculty development for hospitalists: structured peer observation of teaching

BACKGROUND

Hospitalists provide much of the clinical teaching in internal medicine, yet formative feedback to improve their teaching is rare.

METHODS

We developed a peer observation, assessment, and feedback program to improve attending hospitalist teaching. Participants were trained to identify 10 optimal teaching behaviors using a structured observation tool that was developed from the validated Stanford Faculty Development Program clinical teaching framework. Participants joined year-long feedback dyads and engaged in peer observation and feedback on teaching. Pre- and post-program surveys assessed confidence in teaching, performance of teaching behaviors, confidence in giving and receiving feedback, attitudes toward peer observation, and overall satisfaction with the program.

RESULTS

Twenty-two attending hospitalists participated, averaging 2.2 years (± 2.1 years standard deviation [SD]) experience; 15 (68%) completed pre- and post-program surveys. Confidence in giving feedback, receiving feedback, and teaching efficacy increased (1 = strongly disagree, 5 = strongly agree, mean ± SD): "I can accurately assess my colleagues' teaching skills," (pre = 3.2 ± 0.9 vs post = 4.1 ± 0.6, P < 0.01), "I can give accurate feedback to my colleagues" (pre = 3.4 ± 0.6 vs post = 4.2 ± 0.6, P < 0.01), and "I am confident in my ability to teach students and residents" (pre = 3.2 ± 0.9 vs post = 3.7 ± 0.8, P = 0.026).

CONCLUSIONS

Peer observation and feedback of teaching increases hospitalist confidence in several domains that are essential for optimizing teaching. Further studies are needed to examine if educational outcomes are improved by this program.

Improving teaching on an inpatient pediatrics service: a retrospective analysis of a program change

BACKGROUND

The traditional role of the faculty inpatient attending providing clinical care and effectively teaching residents and medical students is threatened by increasing documentation requirements, pressures to increase clinical productivity, and insufficient funding available for medical education. In order to sustain and improve clinical education on a general pediatric inpatient service, we instituted a comprehensive program change. Our program consisted of creating detailed job descriptions, setting clear expectations, and providing salary support for faculty inpatient attending physicians serving in clinical and educational roles. This study was aimed at assessing the impact of this program change on the learners' perceptions of their faculty attending physicians and learners' experiences on the inpatient rotations.

METHODS

We analyzed resident and medical student electronic evaluations of both clinical and teaching faculty attending physician characteristics, as well as resident evaluations of an inpatient rotation experience. We compared the proportions of "superior" ratings versus all other ratings prior to the educational intervention (2005-2006, baseline) with the two subsequent years post intervention (2006-2007, year 1; 2007-2008, year 2). We also compared medical student scores on a comprehensive National Board of Medical Examiners clinical subject examination pre and post intervention.

RESULTS

When compared to the baseline year, pediatric residents were more likely to rate as superior the quality of didactic teaching (OR=1.7 [1.0-2.8] year 1; OR=2.0 [1.1-3.5] year 2) and attendings' appeal as a role model (OR=1.9 [1.1-3.3] year 2). Residents were also more likely to rate as superior the quality of feedback and evaluation they received from the attending (OR=2.1 [1.2-3.7] year 1; OR=3.9 [2.2-7.1] year 2). Similar improvements were also noted in medical student evaluations of faculty attendings. Most notably, medical students were significantly more likely to rate feedback on their data gathering and physical examination skills as superior (OR=4.2 [2.0-8.6] year 1; OR=6.4 [3.0-13.6] year 2).

CONCLUSIONS

A comprehensive program which includes clear role descriptions along with faculty expectations, as well as salary support for faculty in clinical and educational roles, can improve resident and medical student experiences on a general pediatric inpatient service. The authors provide sufficient detail to replicate this program to other settings.

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.

Primary care physicians and hospitalists: two branches of the same tree

The success of the evolving filed of pediatric hospitalist medicine should be judged on the health outcomes achieved for the more than 6 million children who are hospitalized annually. The focused approach hospitalists bring to defining the best knowledge that their role is important but is limited in the overall health of most children. In order to achieve the best health outcomes, hospitalists must fully partner with the child's primary care provider. By consistently communicating well during pre-admission, hospitalization, and discharge intervals, hospitalists and primary care pediatricians can enhance learning, as well as maximize outcomes for shared patients.

Hospitalists' involvement in pediatrics training: perspectives from pediatric residency program and clerkship directors

PURPOSE

To explore the use and perceived impact of pediatric hospitalists as teaching attendings among pediatric residency and clerkship programs.

METHOD

Between November 2007 and February 2008, the authors conducted a mail-based survey of all pediatric residency program directors (170) and pediatric clerkship directors (131) in the United States as identified by the Association of Pediatric Program Directors and Council on Medical Student Education in Pediatrics. The surveys focused on the responsibilities of pediatric hospitalists in training programs and their perceived impact on the roles of pediatric residents and medical students.

RESULTS

The response rate for residency directors was 86% (146/170) and 87% (114/131) for clerkship directors. One hundred thirteen (77%) residency programs and 91 (80%) clerkship programs used hospitalists as teaching attendings. Among these programs, 65% (73) of residency program directors and 64% (58) of clerkship directors reported that pediatric hospitalists are responsible for all general inpatient services. The majority of residency (76%, 84) and clerkship directors (71%, 64) reported that hospitalists are more accessible to trainees than traditional attendings. A minority of residency program directors (36%, 39) reported that use of hospitalists has decreased senior resident autonomy.

CONCLUSIONS

The role of hospitalists in resident and student education will likely continue to evolve over the next decade.Additional refinement of the roles and responsibilities of hospitalists will address lingering concerns in some programs about resident autonomy.

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

BACKGROUND

Trainees receive much of their inpatient education from hospitalists.

PURPOSE

To characterize the effects of hospitalists on trainee education.

DATA SOURCES

MEDLINE, Database of Reviews of Effectiveness (DARE), National Health Service (NHS) Economic Evaluation Database (EED), Health Technology Assessment (HTA), and the Cochrane Collaboration Database (last searched October 2008) databases using the term "hospitalist", and meeting abstracts from the Society of Hospital Medicine (SHM) (2002-2007), Society of General Internal Medicine (SGIM) (2001-2007), and Pediatric Academic Societies (PAS) (2000-2007).

STUDY SELECTION

Original English language research studies meeting all of the following: involvement of hospitalists; comparison to nonhospitalist attendings; evaluation of trainee knowledge, skills, or attitudes. 711 articles were reviewed, 32 retrieved, and 6 included; 7,062 meeting abstracts were reviewed, 9 retrieved, and 2 included.

DATA EXTRACTION

Two authors reviewed articles to determine study eligibility. Three authors independently reviewed included articles to abstract data elements and classify study quality.

DATA SYNTHESIS

Seven studies were quasirandomized one was a noncontemporaneous comparison. All citations only measured trainee attitudes. In all studies comparing hospitalists to nonhospitalists, trainees were more satisfied with hospitalists overall, and with other aspects of their teaching, but ratings were high for both groups. One of 2 studies that distinguished nonhospitalist general internists from specialists showed that trainees preferred hospitalists, but the other did not demonstrate a hospitalist advantage over general internists.

CONCLUSIONS

Trainees are more satisfied with inpatient education from hospitalists. Whether the increased satisfaction translates to improved learning is unclear.

Neurohospitalists: an emerging model for inpatient neurological care

Over the past decade, the hospitalist model has become a dominant system for the delivery of general adult and pediatric inpatient care. Similar forces, including national mandates to improve safety and quality and intense pressure to safely reduce length of hospital stays, that led to the remarkable growth of hospitalist medicine are now exerting pressure on neurologists. A neurohospitalist model, in which inpatient neurology specialists deliver high-quality and efficient care to neurology patients, is emerging to meet these challenges. Benefits of this system may include more frequent, timely neurology consultations in the hospital and emergency department, as well as improved quality of inpatient neurological education for residents and medical students. Challenges will involve defining the relationship of neurohospitalists with primary stroke centers, the economic feasibility of such neurohospitalist systems, and how to train members of this new field. A neurohospitalist model of care is an emerging idea in neurology that would overcome many regulatory, educational, and economic challenges facing neurologists; further research is needed to gauge the effects of this innovative approach.

Third-year medical students' evaluation of hospitalist and nonhospitalist faculty during the inpatient portion of their pediatrics clerkships

BACKGROUND

Although the data on the impact of hospitalist programs on the inpatient education of medical students during their internal medicine clerkships are favorable, the data is limited on the inpatient educational experience of medical students during their pediatric clerkships. The purpose of this study was to compare the evaluations of hospitalist and nonhospitalist faculty of third-year medical students during their inpatient pediatrics rotations.

METHODS

We performed a retrospective study of the evaluations of third-year medical student of hospitalist and nonhospitalist faculty during their inpatient pediatrics rotations at Penn State Children's Hospital from July 1999 through September 2000. Using a 4-point scale, students gave an overall evaluation and also rated the hospitalist and nonhospitalist faculty on effectiveness as teachers, effectiveness as pediatricians, and effectiveness as student advocates. Using the same 4-point scale, students rated the following aspects of the rotation: ward rounds, sick newborn care, well newborn care, outpatient clinics, private physician's office, noon conferences, and morning report.

RESULTS

A total of 67 students rotated on the pediatric inpatient service during the study period; 35 students rotated with 2 hospitalists, and 32 students rotated with 8 nonhospitalists. All 67 students (100%) submitted an evaluation. The hospitalists received higher scores than nonhospitalists on effectiveness as teachers (3.87 vs. 2.91; P < 0.001), effectiveness as pediatricians (3.94 vs. 3.25; P < .001), effectiveness as student advocates (3.76 vs. 2.97; P < .001), and in the overall evaluation (3.93 vs. 3.06; P < .001). Ward rounds were rated as more beneficial when conducted by hospitalists then when conducted by nonhospitalists (3.15 vs. 2.58; P < .006).

CONCLUSIONS

Hospitalists were perceived by third-year medical students as providing more effective teaching and more satisfying overall rotations than were nonhospitalists during the inpatient portion of the students' pediatric clerkships. Further studies that examine inpatient systems, particularly as they relate to the acquisition of knowledge and the development of effective communication skills in medical learners, are needed.

Preparing for "diastole": advanced training opportunities for academic hospitalists

Academic hospital medicine can be described as comprising periods of "systole," during which hospitalists provide clinical care, and periods of "diastole," the portion of a hospitalist's time spent in nonclinical activities. Far from being a period of relaxation, diastole is an active component of a hospitalist's work, the time devoted to the pursuit of career advancement. This period is a critical opportunity for career development in terms of medical research, education, quality improvement, or administration. An appropriate balance of systole and diastole may potentially prevent burnout and allow hospitalists opportunities to focus on academic advancement. Although an increasing number of residency graduates opt for a career in academic hospital medicine, few are prepared for the period of diastole. This article describes several career options in academic hospital medicine, specifically, opportunities in education, research, quality improvement, and administrative opportunities. By informing future hospitalists about the career opportunities within academic hospital medicine possible through managing their diastolic time, we hope that future generations of trainees will be better prepared to enter this field.

Pediatric hospitalists: report of a leadership conference

OBJECTIVES

To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field.

METHODS

The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed.

RESULTS

More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees.

CONCLUSIONS

Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Hospitalists: Evolution, evidence, and eventualities

Hospitalists are physicians who spend at least 25% of their professional time serving as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge. The hospitalist movement is only about 5 years old, yet at least 7000 hospitalists practice today and an estimated 19,000 will ultimately practice, approximately the current number of emergency medicine physicians. The emerging positivist literature on hospitalists' impact is the subject of this review. It traces the nature and evolution of the hospitalist movement; summarizes empirical evidence about costs, clinical outcomes, patient satisfaction, and education; and appraises whether the hospitalist model is indeed novel. The review concludes by outlining research questions about the hospitalist model's viability over time, the mechanisms by which it produces benefits, and especially hospitalists' longitudinal effect on continuity of patient care. A literature "scorecard" might rank evidence to date on costs as positive, evidence on clinical outcomes and education as nonnegative, and evidence on patient satisfaction and continuity of care as inconclusive. Above all, longitudinal research must illuminate whether hospitalists' advantages comeat the cost of the doctor-patient relationship.

Community and hospital-based physicians' attitudes regarding pediatric hospitalist systems

OBJECTIVE

Pediatric hospitalist systems are being implemented widely. Their implementation may be influenced by physician attitudes, which may vary according to practice type (eg, community or hospital-based practice) and personal characteristics (eg, age and practice location). Little evidence exists to describe factors relevant to pediatric systems. The objective of this study was to determine physicians' attitudes regarding hospitalists and associated physician and practice characteristics.

METHODS

We used a cross-sectional survey of all physicians with admitting privileges at a tertiary-care, pediatric, teaching hospital in the Intermountain West in April 2002. Outcomes included survey responses indicating attitudes toward the effects of the hospitalist system on quality of care, patient satisfaction, and teaching.

RESULTS

A total of 313 of 368 physicians (85%) responded, 191 of whom (61%) were community physicians; 224 respondents (72%) spent the majority of their time in outpatient care. Community physicians more often characterized inpatient care as an inefficient use of time (45% vs 25%) but were less likely to think that hospitalists would improve the quality of care (49% vs 68%) or increase patient satisfaction (10% vs 30%). In multivariate models examining predictors of overall attitudes toward hospitalists, being a community physician (6.4 points more negative) and admitting patients at >1 hospital (3.3 points more negative) were associated with less favorable attitudes. Being <40 years of age (4.5 points more positive) and practicing >13 miles from the hospital (4.3 points more positive) were associated with more positive attitudes.

CONCLUSIONS

Attitudes regarding hospitalist systems differ between physician groups and are influenced by practice characteristics. Understanding these differences and tailoring hospitalist systems to address them will be important as pediatric hospitalist systems are implemented nationwide.

The positive impact of initiation of hospitalist clinician educators

OBJECTIVE

Although hospitalists have been shown to improve both financial and educational outcomes, their ability to manage dual roles as clinicians and educators has been infrequently demonstrated, particularly in the community setting where large numbers of residents train. We evaluated the impact of hospitalists on financial and educational outcomes at a mid-sized community teaching hospital 1 year after implementation.

DESIGN

Two hospitalist clinician educators (HCEs) were hired to provide inpatient medical care while participating in resident education. Length of stay and cost per case data were calculated for all patients admitted to the hospitalist service during their first year and compared with patients admitted to private physicians. The hospitalists' top 11 discharge diagnoses were individually assessed. For the same time period, categorical medicine residents (N = 36) were given an anonymous written survey to assess the HCEs' impact on resident education and service.

RESULTS

Resource consumption: length of stay was reduced by 20.8% and total cost per case was reduced by 18.4% comparing the HCEs with community-based physicians. Reductions in both length of stay and cost per case were noted for 8 of the 11 most common discharge diagnoses. Resident survey: over 75% of residents responded, with all noting improvement in the quality of attending rounds, bedside teaching, and the overall inpatient experience. Residents' roles as teachers and team leaders were largely unchanged.

CONCLUSION

Hospitalist clinician educators as inpatient teaching attendings effectively reduce length of stay and resource utilization while improving resident education at community-based teaching hospitals.

Hospitalists as teachers

OBJECTIVE

To compare evaluations of teaching effectiveness among hospitalist, general medicine, and subspecialist attendings on general medicine wards.

DESIGN

Cross-sectional.

SETTING

A large, inner-city, public teaching hospital.

PARTICIPANTS

A total of 423 medical students and house staff evaluating 63 attending physicians.

MEASUREMENTS AND MAIN RESULTS

We measured teaching effectiveness with the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey, and reviewed additional written comments. The response rate was 81%. On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of subspecialists (126.3 [95% CI, 120.4 to 132.1]), P =.03. General medicine attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than subspecialists, P =.01. Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than did more distant graduates (129.1 [95% CI, 125.1 to 133.1]), P =.006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P =.05. Qualitative analysis of written remarks revealed that trainees valued faculty who were enthusiastic teachers, practiced evidence-based medicine, were involved in patient care, and developed a good rapport with patients and other team members. These characteristics were most often noted for hospitalist and general medicine attendings.

CONCLUSIONS

On general medicine wards, medical students and residents considered hospitalists and general medicine attendings to be more effective teachers than subspecialists. This effect may be related to the preferred faculty members exhibiting specific characteristics and behaviors highly valued by trainees, such as enthusiasm for teaching and use of evidence-based medicine.

Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations

PURPOSE

To evaluate the impact of academic hospitalists on third-year medical students during inpatient medicine rotations.

METHOD

The authors conducted a retrospective quantitative assessment of medical student evaluations of hospitalist and nonhospitalist Department of Medicine faculty at Oregon Health & Science University, for the 1998-00 academic years. Using a nine-point Likert-type scale, students evaluated the faculty on the following characteristics: communication of rotation goals, establishing a favorable learning climate, use of educational time, teaching style, evaluation and feedback, contributions to the student's growth and development, and overall effectiveness as a clinical teacher.

RESULTS

A total of 138 students rotated on the university wards during the study period; 100 with hospitalists, and 38 with nonhospitalists. Of these students, 99 (71.7%) returned evaluations. The hospitalists received higher numeric evaluations for all individual attending characteristics. Significance was achieved comparing communication of goals (p =.011), effectiveness as a clinical teacher (p =.016), and for the combined analysis of all parameters (p <.001). Despite lack of achieving statistical significance, there was a trend toward hospitalists being more likely to contribute to the medical student's perception of growth and development during the period evaluated (p =.065).

CONCLUSIONS

In addition to performing the responsibilities required of full-time hospital-based physicians, hospitalists were able to provide at least as positive an educational experience as did highly rated nonhospitalist teaching faculty and in some areas performed better. A hospitalist model can be an effective method of delivering inpatient education to medical students.

Subspecialty training in the ambulatory clinic: a preliminary investigation of an endocrinology curriculum

PURPOSE

There is scant literature on education in the ambulatory subspecialty clinic. This preliminary study was conducted to investigate subspecialty education, using endocrinology as a model.

METHOD

In 2002, a questionnaire was mailed to 90 former University of Virginia internal medicine (IM) residents who completed training between 1998 and 2001. The questionnaire asked how well residency prepared them to take care of patients with various endocrine disorders, and to state the best and worst parts of their endocrine training. In 2001-02, 11 fourth-year medical students and 26 senior IM residents rotating on the endocrinology service were asked to record their patient encounters in logbooks. This information was compared to the perceived strengths and weaknesses of endocrine training.

RESULTS

Sixty-one residents (68%) completed questionnaires. Significant differences were found in perceived preparedness to care for patients with various endocrine disorders, with diabetes, hypothyroidism, and osteoporosis as strengths and reproductive disorders representing a significant weakness. Fifteen residents (58%) and ten students (91%) completed logs. The logbooks revealed that current learners were well exposed to patients with diabetes and thyroid disorders during the block rotation, but saw relatively few patients with other endocrine disorders.

CONCLUSION

Former IM residents felt well prepared by residency to manage certain common endocrine problems, but felt significantly less prepared for other problems, most notably reproductive disorders. University of Virginia's curriculum was modified using information from this study to improve the educational experience in endocrinology. More studies are needed to define optimal strategies for teaching and learning in the subspecialty clinic.

The Rotating Hospitalist: A Solution for an Academic Internal Medicine Practice

BACKGROUND

Concerns have been raised about the role that hospitalists may have in changing the educational process for medical students and residents, especially with regard to the primary care specialties.

METHODS

We implemented rotating hospital and office duties within our five-physician group.

RESULTS

Resident and student satisfaction increased, and additional faculty members could be added without expanding office space. Financial benefits then also ensued.

CONCLUSION

Rotating hospital with office duties among a small group of internists has resulted in most of the advantages with few of the drawbacks related to the hospitalist approach.