Response to the Effect of Hospitalist Systems on Residency Education

Objective: Over the past several years, the hospitalist movement has gained momentum in inpatient internal medicine settings. Both academic medical centers and community hospitals have increasingly relied upon hospital-based internists for delivery of care. While outcome studies have demonstrated lower costs and increased quality of care, little research has been done to assess the educational impact of this system. At our institution, implementation of a hospitalist system has resulted in overall improved evaluations of teaching on the inpatient service. However, in narrative comments, residents have expressed concern about the decreased visibility of and contact with subspecialty faculty members who have traditionally been important teachers and mentors. In response, we formulated a strategy to enhance residents' interaction with faculty who no longer have educational responsibilities on the inpatient medical service. Description: For the past three years, Moffitt—Long Hospital at the University of California, San Francisco, has employed an academic hospitalist model on its medical service. Approximately 80% of inpatient attending is now done by hospitalists, most of whom are general internists. This has significantly reduced the number of attending months staffed by other faculty, many of whom are research-oriented subspecialists. Over the past year, we have begun a multitiered effort to reengage subspecialty faculty in residency education. The effort has the following components. (1) A subset of resident morning reports has been devoted to subspecialty sessions, during which the residents present patients to subspecialty faculty for discussion. (2) A monthly residency journal club now rotates among subspecialty divisions, with designated faculty members supporting resident discussants and hosting these sessions in their homes. (3) Annual subspecialty-based fellowship evenings have been organized to provide outreach to interested residents, foster mentorship, and provide detailed guidance about the fellowship application process. (4) A new subspecialty elective month has been created during the PGY1 to allow residents to encounter a broader range of subspecialty faculty early in residency training. (5) A monthly “bench to bedside” conference has been incorporated into the noon conference didactic series; it features biomedical researchers discussing the scientific underpinnings of clinical problems. Discussion: In academic settings, hospitalist systems may result in significant educational benefits by selecting physicians who are particularly interested in teaching residents and students. However, the concentration of attending time among a small group of predominantly generalist faculty may decrease the amount of contact that trainees have with other faculty, especially those who spend the majority of their time doing subspecialty-based biomedical research. This may have negative consequences for education, mentoring, and career development. Thus far, our residents have found that the new approach we have implemented recaptures opportunities to establish links with subspecialty faculty in a variety of formal educational and social settings. Subspecialty faculty members involved in these activities report an increased sense of connection with the training program. We encourage programs using hospitalist models to find novel ways of having trainees interact with a valuable group of faculty suddenly rendered less accessible by this system of care.