Hospital medicine beyond the United States

Trainee Autonomy and Supervision in the Inpatient Clinical Learning Environment

BACKGROUND

Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the increasingly complex inpatient clinical learning environment, tension exists when this balance is skewed. In this study, we aimed to understand current and ideal states of autonomy and supervision and then describe factors that contribute to imbalance from both trainee and attending perspectives.

METHODS

A sequential mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019 and June 2020. Survey responses were compared using t-tests, chi-square tests or Fisher's exact tests. Open-ended survey and focus group data were analysed using thematic analysis.

FINDINGS

Survey response rate was 42% (76/182) for trainees and 49% (101/208) for attendings. Fourteen trainees and 32 attendings participated in 14 focus groups. Trainees perceived current culture to be significantly more autonomous than attendings; both groups described 'ideal' culture as more autonomous than current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending, trainee, patient, interpersonal and institutional. These factors were found to be complex and interactive and require frequent adjustment to avoid tension.

CONCLUSIONS

Trainees and attendings agree that resident autonomy should be prioritized more than it currently is. Attendings, trainees and patients contribute to a complex dynamic between autonomy and supervision, further impacted by both interpersonal and institutional factors, in the inpatient clinical learning environment. Capturing complex interactions between individual factors that impact this dynamic is critical to understanding and optimization by both trainees and attending.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

BACKGROUND

Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited.

METHODS

This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed.

RESULTS

Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs.

CONCLUSIONS

Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.

Roles considered important for hospitalist and non-hospitalist generalist practice in Japan: a survey study

BACKGROUND

An increased focus on quality and patient safety has led to the evolution of hospitalists. The number of hospitalists covering ward and outpatient care is on the rise in Japan. However, it is unclear what roles hospital workers themselves consider important in their practice. Therefore, this study investigated what hospitalists and non-hospitalist generalists in Japan consider important for the practice of their specialty.

METHODS

This was an observational study that included Japanese hospitalists (1) currently working in a general medicine (GM) or general internal medicine department and (2) working at a hospital. Using originally developed questionnaire items, we surveyed the items important to hospitalists and non-hospitalist generalists.

RESULTS

There were 971 participants (733 hospitalists, 238 non-hospitalist) in the study. The response rate was 26.1%. Both hospitalists and non-hospitalists ranked evidence-based medicine as the most important for their practice. In addition, hospitalists ranked diagnostic reasoning and inpatient medical management as the second and third most important roles for their practice, while non-hospitalists ranked inpatient medical management and elderly care as second and third.

CONCLUSIONS

This is the first study investigating the roles Japanese hospitalists consider important and comparing those to that of non-hospitalist generalists. Many of the items that hospitalists considered important were those that hospitalists in Japan are working on within and outside academic societies. We found that diagnostic medicine and quality and safety are areas that are likely to see further evolution as hospitalists specifically emphasized on them. In the future, we expect to see suggestions and research for further enhancing the items that hospital workers value and emphasise upon.

Gender differences in COVID-19-related manuscript authorship by hospitalists during the pandemic: A bibliometric analysis

BACKGROUND

Hospital medicine (HM) has a well-described gender disparity related to academic work and promotion. During the COVID-19 pandemic, female authorship across medicine fell further behind historical averages.

OBJECTIVE

Examine how COVID-19 affected the publication gender gap for hospitalists.

DESIGN, SETTINGS, AND PARTICIPANTS

Bibliometric analysis to determine gender and specialty of US-based physician first and last authors of COVID-19 articles published March 1, 2020 to February 28, 2021 in the four highest impact general medical journals and two highest impact HM-specific journals.

MAIN OUTCOME AND MEASURES

We characterized the percentage of all physician authors that were women, the percentage of physician authors that were hospitalists, and the percentage of HM authors that were women. We compared author gender between general medical and HM-specific journals.

RESULTS

During the study period, 853 manuscripts with US-based first or last authors were published in eligible journals. Included manuscripts contained 1124 US-based physician first or last author credits, of which 34.2% (384) were women and 8.8% (99) were hospitalists. Among hospitalist author credits, 43.4% (n = 43/99) were occupied by women. The relative gender equity for hospitalist authors was driven by the two HM journals where, compared to the four general medical journals, hospitalist authors (54.1% [33/61] vs. 26.3% [10/38] women, respectively, p = .002) and hospitalist last authors (51.9% [14/27] vs. 20% [4/20], p = .03) were more likely to be women.

CONCLUSIONS

Across COVID-19-related manuscripts, disparities by gender were driven by the high-impact general medical journals. HM-specific journals had more equitable inclusion of women authors, demonstrating the potential impact of proactive editorial policies on diversity.

COVID-19-Related Publications by Hospitalists in the United States

Objective To determine the degree to which hospitalists published academic manuscripts related to COVID-19 during the first year of the pandemic. Patients and methods The study was a cross-sectional analysis of the author's specialty, defined by byline or professional online biography, from articles related to COVID-19 published between March 1, 2020, and February 28, 2021. It included the top four internal medicine journals by impact factor: New England Journal of Medicine, Journal of the American Medical Association, Journal of the American Medical Association Internal Medicine, and Annals of Internal Medicine. Participants were all United States (US)-based physician authors contributing to COVID-19 publications. Our primary outcome was the percentage of US-based physician authors of COVID-19 articles who were hospitalists. Subgroup analyses characterized author specialty by authorship position (first, middle, last) and article type (research vs. non-research). Results Between March 1, 2020, and February 28, 2021, the top four US-based medical journals published 870 articles related to COVID-19 of which 712 articles with 1940 US-based physician authors were included. Hospitalists accounted for 4.2% (82) of authorship positions including 4.7% (49/1038) of authorship positions in research articles and 3.7% (33/902) of authorship positions in non-research articles. First, middle, and last authorship positions were held by hospitalists at 3.7% (18/485), 4.4% (45/1034), and 4.5% (19/421) of the time, respectively. Conclusions Despite caring for a large number of patients with COVID-19, hospitalists were rarely involved in disseminating COVID-19 knowledge. Limited authorship by hospitalists could constrain the dissemination of inpatient medicine knowledge, impact patient outcomes, and affect the academic promotion of early-career hospitalists.

Inpatient clinician workload: a scoping review protocol to understand the definition, measurement and impact of non-procedural clinician workloads

INTRODUCTION

Clinicians that care for hospitalised patients face unprecedented work conditions with exposure to highly infectious disease, exceedingly high patient numbers, and unpredictable work demands, all of which have resulted in increases in stress and burnout. Preliminary studies suggest that increasing workloads negatively affect inpatient clinician well-being and may negatively affect job performance; yet high workloads may be prioritised secondary to financial drivers or from workforce shortages. Despite this, the correlation between workload and these negative outcomes has not been fully quantified. Additionally, there are no clear measures for inpatient clinician workload and no standards to define ideal workloads. Using the protocol described here, we will perform a scoping review of the literature to generate a comprehensive understanding of how clinician workload of medical patients is currently defined, measured in clinical settings and its impact on the workforce, patients and institutional outcomes.

METHODS AND ANALYSIS

We will follow the methodology outlined by Joanna Briggs Institute and Arksey and O'Malley to conduct a comprehensive search of major electronic databases including Ovid Medline (PubMed), Embase (Embase.com), PsycINFO, ProQuest Dissertations and Google Scholar. All relevant published peer-reviewed and dissertaion grey literature will be included. Data will be extracted using a standardised form to capture key article information. Results will be presented in a descriptive narrative format.

ETHICS AND DISSEMINATION

This review does not require ethics approval though all included studies will be screened to ensure appropriate approval. The synthesis of this literature will provide a better understanding of the current state of work for inpatient clinicians, associated outcomes, and will identify gaps in the literature. These findings will be used in conjunction with an expert Delphi panel to identify measures of inpatient clinician workload to then guide the development of a novel workforce mobile application to actively track clinician work. We aim to lay the groundwork for future workforce studies to understand the optimal workloads that drive key outcomes for clinicians, patients and institutions.

Characteristics of the ideal hospitalist inpatient care program: perceptions of Canadian health system leaders

Background

Despite the growing prevalence of hospitalist programs in Canada, it is not clear what program features are deemed desirable by administrative and medical leaders who oversee them. We aimed to understand perceptions of a wide range of healthcare administrators and frontline providers about the implementation and necessary characteristics of a hospitalist service.

Methods

We conducted semi-structured interviews with a range of administrators, medical leaders and frontline providers across three hospital sites operated by an integrated health system in British Columbia, Canada.

Results

Most interviewees identified the hospitalist model as the ideal inpatient care service line, but identified a number of challenges. Interviewees identified the necessary features of an ideal hospitalist service to include considerations for program design, care and non-clinical processes, and alignment between workload and physician staffing. They also identified continuity of care as an important challenge, and underlined the importance of communication as an important enabler of implementation of a new hospitalist service.

Conclusions

Most hospital administrators and frontline providers in our study believed the hospitalist model resulted in improvements in clinical processes and work environment.

The Analgesic Effect of Transcutaneous Electrical Acupoint Stimulation on Labor: A Randomized Control Study

Objective

This study aimed to investigate the analgesic effect of transcutaneous electrical acupoint stimulation (TEAS) on labor.

Methods

Primiparas with single birth and head presentation were enrolled in this study and randomly divided into three groups: TEAS group (n = 76), patient-controlled epidural analgesia (PCEA) group (n = 75), and control group without any analgesic measures (n = 78).

Results

Compared with the control group, the visual analog scores of the TEAS group and the PCEA group at each time point decreased (P < 0.01). The decrease was greater in the PCEA group than that in the TEAS group (P < 0.01). At 120 minutes after analgesia, there were significant differences in plasma β-endorphin content between the TEAS group, PCEA group, and control group (P < 0.01). The difference between the PCEA group and the control group was statistically significant (P < 0.01). Among the parturients having a vaginal delivery, the duration of the first stage of labor was significantly shorter in the TEAS group and control group than in the PCEA group (P < 0.01). The duration of the second stage of labor was significantly shorter in the TEAS group than in the PCEA group (P < 0.01). Oxytocin usage rate during labor was significantly lower in the TEAS group and control group than in the PCEA group (P < 0.01), and adverse reactions were significantly fewer in the TEAS group and control group than in the PCEA group (P < 0.01).

Conclusion

The duration of the first and second stage of labor is significantly shorter in the TEAS group than in the PCEA group. TEAS does not increase the use rate of oxytocin or the rate of cesarean section and will not bring about obvious maternal or fetal adverse reactions.

Perspectives on and barriers to research among advanced practice provider and physician hospitalists

Advanced practice providers and physicians at an academic healthcare system comprising more than 15 hospitals across four US states were surveyed to identify barriers to participation in research. Overall, barriers reported by advanced practice providers and physicians were more similar than different, highlighting system-level opportunities to build research skills and accelerate academic productivity.

Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea

BACKGROUND

The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists.

METHODS

A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI).

RESULTS

HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points.

CONCLUSION

Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

The effect of racial and gender concordance between physicians and patients on the assessment of hospitalist performance: a pilot study

BACKGROUND

Lack of racial concordance between physicians and patients has been linked to health disparities and inequities. Studies show that patients prefer physicians who look like them; however, there are too few underrepresented minority physicians in the workforce. Hospitalists are Internal Medicine physicians who specialize in inpatient medicine. At our hospital, hospitalists care for 60% of hospitalized medical patients. We utilized the validated Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) to assess the effect of patient-provider race and gender concordance on patients' assessment of their physician's performance.

METHODS

Four hundred thirty-seven inpatients admitted to the non-teaching hospitalist service, cared for by a unique hospitalist physician for two or more consecutive days, were surveyed using the validated TAISCH instrument. The influence of gender and racial concordance on TAISCH scores for patient - hospitalist pairs were assessed by comparing the specific dyads with the overall mean scores. T-tests were used to compare the means. Generalized estimating equations were used to account for clustering.

RESULTS

Of the 34 hospitalist physicians in the analysis, 20% were African American (AA-non-Hispanic), 15% were Caucasians (non-Hispanic) and 65% were in the "other" category. The "other" category consisted of predominantly physicians of South East Asian decent (i.e. Indian subcontinent) and Hispanic. Of the 437 patients, 66% were Caucasians, and 32% were AA. The overall mean TAISCH score, as these 437 patients assessed their hospitalist provider was 3.8 (se = 0.60). The highest mean TAISCH score was for the Caucasian provider-AA patient dyads at 4.2 (se = 0.21, p = 0.05 compared to overall mean). The lowest mean TAISCH score was 3.5 (se = 0.14) seen in the AA provider/AA patient dyads, significantly lower than the overall mean (p = 0.013). There were no statistically significant differences noted between mean TAISCH scores of gender and racially concordant versus discordant doctor-patient dyads (all p's > 0.05).

CONCLUSIONS

In the inpatient setting, it appears as if neither race nor gender concordance with the provider affects a patient's assessment of a hospitalist's performance.

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.