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Medical Student Teaching on a “Non-Teaching” Service


 

At many academic institutions, hospitalists are increasingly acting as the teaching attendings on inpatient general medicine rotations. There have been multiple studies demonstrating perceived benefits of hospitalist faculty on housestaff education in academic and community hospitals (1-6). Measured benefits have included improved trainee satisfaction with the educational experience, improved teaching, and higher quality of attending rounds (3,4). There is growing evidence that hospitalist physicians attending on medicine wards provide educational advantages for medical students as well (5-7).

The majority of published studies thus far have focused on trainee education on a traditional medicine ward rotation, with a team including housestaff and medical students. A few medical centers have developed a resident or medical student rotation on a primary hospitalist service (8). With recent restrictions on resident work hours, many more academic programs are developing a “non-covered” hospitalist service similar to the community model (9). While the outcomes of many such programs are not yet entirely clear, this type of service may provide opportunities for an alternative learning experience for medical students. The author is not aware of any published accounts of the medical student experience on such rotations.

Barnes-Jewish Hospital is an urban, 904-bed academic center. The hospitalist program at our institution was initiated as a community model in 2000, with a private service managing patients independent of the internal medicine teaching service. Since then, members of the group have become integrally involved in multiple other teaching roles throughout the institution. The private inpatient service has remained a portion of the practice. During this time period, fourth-year medical students have had the opportunity to participate in a 4-week clinical elective on our primary hospitalist service as a substitute for, or in addition to, the traditional internal medicine sub-internship.

This rotation differs from the traditional medicine rotation in that students have the opportunity to be exposed to more patients, as multiple patients are admitted each day, rather than on a rotating call schedule. Students work directly with hospitalists on the service without the involvement of housestaff. They are not assigned to a specific attending, and therefore work with several attendings over the course of the rotation. A single student rotates on any given 4-week block. There are no other support staff involved in patient care, such as physician assistants or nurse practitioners. Over the last 4 years, over 30 students have participated in this rotation.

In 4 years, students have enrolled in approximately 75% of the elective block rotations available. Overall, written feedback has been obtained from 21 students. Students have been asked to rate the quality of teaching, meaningful participation in patient care, and overall satisfaction with the rotation, as well as to provide additional comments on their experience. Ratings were on a five-point scale, ranging from poor to excellent. Review of student evaluations of this rotation over the past 4 years reveals a majority rating of excellent or very good in all three categories (17/21).

In the students’ narrative comments, several themes were predominant. Positive feedback included the opportunity for one-on-one interactions with several attendings. Students valued the exposure to multiple role models with unique patient care styles. In addition, many students appreciated the opportunity to see a larger number of patients, given the multiple daily admissions. Students see an average of 16 new admissions during the rotation compared to an average of 10 patients on the traditional sub-internship over the course of 4 weeks.

Students also commented on the diversity of patients seen. Given the high patient census on the service (an average of 30 each day), we are able to be selective and choose learning cases with interesting and varied diagnoses. Several students appreciated the opportunity to perform more procedures, which may be preferentially performed by the housestaff on a traditional medicine rotation.

Many students noted an increased level of independence experienced on this rotation compared with traditional teaching rotations. In other studies, concerns have been voiced regarding resident lack of autonomy while working with a hospitalist attending, who tends to have a more visible presence on the inpatient medicine floors (1,4). These concerns have not been validated by resident or medical student feedback of actual experiences (1,4). At the training level of a third- or fourth-year medical student, not having a resident intermediary may lead to more perceived autonomy, adding to the overall learning experience.

The main reservation expressed by students pertained to the challenge of scheduling dedicated teaching time while attending physicians are busy with patient care. Serving as the primary inpatient caregiver for patients can often lead to an unpredictable daily schedule. This year our hospital has instituted a designated floor for patients on the< hospitalist service. This has allowed centralization of most patient care, providing more time for teaching and more visibility of attending physicians to medical students on the rotation. Another solution may involve the increased use of non-physician practitioners, as are being incorporated into many hospital medicine practices. This could allow the physicians to focus on teaching and on patients with more complex medical issues.

From the physician perspective, having medical students rotate on the service is consistent with our mission as clinician educators. Hospitalists choose a position at an academic institution in part because teaching is a priority. For community hospitalists, working with medical students may offer an option to incorporate teaching into clinical patient care. For academic hospitalists facing more “nonteaching” duties, a similar rotation may allow physicians to incorporate an additional teaching role into such duties. Based on the limited experience at this institution, a hospitalist rotation appears to offer a distinct and positive learning experience for medical students compared with a traditional medicine rotation. More extensive experience in the future may support this as a viable option at more centers. Further study will be necessary to identify an optimal curriculum for such a rotation and to evaluate the impact on students’ career choices and perceptions of the field of internal medicine.

Dr. Quartarolo can be contacted at jquartar@im.wustl.edu.

References

  1. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560-5.
  2. Kulaga ME, Charney P, O’Mahony SP. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med. 2004;19:293-301.
  3. Hauer KE, Wachter RM, McCulloch CE, Woo GA, Auerbach AD. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164:1866-71.
  4. Chung P, Morrison J, Jin L, Levinson W. Humphrey H. Meltzer D. Resident satisfaction on an academic hospitalist service: Time to teach. Am J Med. 2002;112: 597-601.
  5. Kripalani S, Pope AC, Rask K. Hospitalists as teachers. J Gen Intern Med. 2004;19:8-15.
  6. Hunter AJ, Desai SS, Harrison RA, Chan BK. Medical student evaluation of the quality of hospitalist and non-hospitalist teaching faculty on inpatient medicine rotations. Acad Med. 2004;79:78-82.
  7. Hauer KE and Wachter RM. Implications of the hospitalist model for medical students’ education. Acad Med. 2001;76:324-330.
  8. Amin AN. A successful hospitalist rotation for senior medicine residents. Med Educ. 2003;37:1042.
  9. Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;19:392-3.

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