Employing Hospitalists to Improve Residentsʼ Inpatient Learning

Objective: In many hospital settings when residents care for only a portion of inpatients, hospitalists have been employed to accept overflow from the resident teaching service. While such a system may maintain the teaching service at a manageable size, residents often miss out on excellent teaching cases. Furthermore, hospitalists working separately from residents often contribute little to the learning environment, functioning simply to control the workload for residents. We describe a novel model in which hospitalists not only control the size of a teaching service but also actively tailor the case mix on that service to best meet educational goals. Under this model, hospitalists serve as one-on-one bedside teachers, augmenting the efforts of the attending physician. Description: At Valley Children's Hospital in Fresno, California, UCSF-affiliated residents care for a portion of the hospital's inpatients. Historically, residents would admit new patients until they reached a “cap,” then notify the ER so that subsequent patients would be admitted by moonlighting physicians. We saw an opportunity to greatly enhance inpatient education for residents by recruiting experienced teaching faculty as staff hospitalists and integrating them into the teaching service. These physicians now rotate service, serving alternately as hospitalists and as teaching attendings. Two key features of this model are responsible for significant improvements in the learning environment. (1) Hospitalists screen all hospital admissions and choose only select patients for the teaching service, assuming responsibility for the rest themselves. Guidelines for selecting patients have been developed, so that the selection takes into account the educational value of individual cases, the current case mix on the teaching service, and learning objectives and needs of individual residents. Frequent daily discussions between the admitting hospitalist and the senior resident ensure that this process remains dynamic. (2) Whenever complex new patients are admitted after hours, hospitalists are responsible for supervising and teaching residents at the bedside. This takes the place of nighttime telephone supervision by the team's attending physician (responsibility for the patients is transferred to the attending physician the following morning at a shared sign-out). Our model thus provides more frequent bedside interactions between housestaff and faculty than in a traditional model, and it creates an interactive learning environment throughout the night. Discussion: Since this model was instituted, the residents' average evaluation scores for the inpatient rotation have increased from 4.4 to 5.6 on a six-point scale. Narrative comments, including those of residents who have experienced both systems, reflect enthusiasm for the improved case mix and for the more extensive and timely interactions with teaching faculty when new patients are admitted. The effect on case mix has been particularly dramatic during viral epidemics (RSV, rotavirus, etc.), where previously much of a resident's time was spent caring for patients with a single diagnosis. Now, even during such epidemics, their clinical exposures remain varied. This model could be implemented wherever hospitalists care for a portion of hospitalized patients. In community hospital settings, unusual cases could be favored for their teaching value, while in tertiary care centers, general cases might be selected to best support general training.