Hospitalists And The Learning Environment

Abstract

The role of today’s teaching attending hospitalist has evolved significantly compared to past faculty attendings. Hospitalists’ attending rounds have consistently demonstrated higher quality and value than those of traditional faculty attendings. Academic hospitalists are tasked with balancing the delivery of excellent patient care, maintaining operational efficiency, and providing optimal medical education within academic settings.

The trajectory of hospital medicine and the early gains garnered in the quality and cost-effectiveness of care made an eventual in-depth involvement in medical education inevitable. Hospitalists’ involvement in medical education gained ascendency about two decades ago. By 2016, nearly all teaching hospitalists and 75% of U.S. hospitals had hospitalists on their medical staff. After the initial palpable gains in quality of patient care and cost-effectiveness of care through lower inpatient length of stay, it was a matter of time before these gains were leveraged in other aspects of inpatient care. Co-management models have been developed to enhance inpatient care in areas such as cardiology, hematology/oncology, and surgical disciplines such as orthopedics and urology.¹

Prior to the advent of the hospitalist system, faculty physicians supervised the care of patients on the medical service and were responsible for resident and medical student education. Attending physicians were often subspecialists and often senior faculty members. They served as attendings for 1 or 2 months per year. They made rounds with the residents and students for 1 to 2 hours per day while trying to maintain their other academic, clinical obligations and/or research activities. They spent most of their time on rounds, seeing new patients or patients with interesting or complex problems.

The typical teaching attending hospitalist at present is quite different from the faculty attendings of the past. Hospitalists today are general internists with a greater interest in inpatient care and teaching than research. They directly supervise the workup and care of each patient on the medical service. The duration of hospitalists’ assignment to the teaching service varies based on several factors, such as years of experience, skill set, and other program-specific requirements and average, at least 3-4 months per year.

Many comparison studies between the traditional and hospitalist models have been undertaken in institutions such as the University of Chicago, the University of Oregon, Hauer et al., Kulaga et al., and Kripalani et al.^2–6 Each of these five studies used different questionnaires to compare teaching by hospitalists and non-hospitalists, some more elaborate than others. However, all five studies showed that residents and medical students concluded that the quality and value of hospitalists’ attending rounds was superior to the teaching of traditional faculty attendings. The on-site presence and supervision to help learners navigate the dynamic academic healthcare systems were major factors accounting for these results. Academic medical centers offer a physical space to support the acquisition, development, and application of medical knowledge. The ability to interact with others is a crucial part of the learning process. Amid the current technology boom, we now also have the option of online learning or e-learning.⁷

There are four major categories of learners: Visual, auditory, read/writing, and kinesthetic. While each of us has a dominant mode of acquiring knowledge, we all learn from multiple sources or categories. Hospitalists are uniquely positioned to fulfill the requirements of medical students and residents who fall into all these categories. Onsite supervision offers learners the chance to observe clinical educators in acute care environments, demonstrating exemplary professional behavior under stress and navigating evolving healthcare systems, including electronic medical records.

The challenge for hospitalists is balancing the three-legged stool: Optimal patient care, operational excellence and medical education. It has been stated that there is no academic mission where there is no money. However, no academic mission alludes to no investment in the future of healthcare. The focus on patient throughput and the availability of advanced technology should not compromise the training necessary for students and residents to build clinical skills through bedside interactions and repeated patient observations. Ancillary testing and data should complement our clinical skill sets, not replace them.^8,9

Hospitalists will be better suited to meet the challenge of ensuring the required education in academic settings by

• Building on the basics: Emphasizing history taking, physical examination, clinical reasoning, and use of pertinent ancillary tests.

• Imbibing the key requirements and resolving obstacles that hinder the creation of a highly effective learning environment. Table 1 shows the ten major characteristics of a highly effective learning environment.¹⁰

• Providing a forum for timely, productive, bidirectional feedback for medical students and residents.

Table 1. 10 Characteristics of a Highly Effective Learning Environment.

1	The students ask more questions than the teachers
2	Questions are valued over answers
3	Ideas come from divergent sources
4	A variety of learning models are used
5	Classroom learning empties into connected community
6	Learning is personalized by a variety of criteria
7	Assessment is persistent, authentic, transparent and never punitive
8	The criterion for success is diverse, transparent and co-created with students and families
9	Learning habits are constantly modeled
10	There are constant and creative opportunities for practice and growth

Time spent in medicine is at a premium, and patients expect to be examined. To quote Osler, “To educate the eye to see, the ear to hear, and the finger to feel takes time.” According to Lewis Thomas, “touching” is considered the “real professional secret” of doctors, describing it as the “oldest and most effective art of doctors” that may possess therapeutic value.^4,5

Disclosures/Conflicts of Interest

The author has no conflicts of interest to disclose

Corresponding Author:

Kwame Dapaah-Afriyie, MD

Professor of Medicine, Clinical Educator

Warren Alpert Medical School at Brown University

Division Director

Division of Hospital Medicine

The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906