Medicolegal Issues

Hail Fellows


Because hospital medicine is still a new specialty, the finer points of hospitalist education and training are being developed. According to two papers in this month’s Journal of Hospital Medicine, students, hospitalists, employers—even patients—are eager for programs that allow hospitalists to hone their skills.

In one study, investigators at the University of California, San Francisco (UCSF), designed a program for third-year medical students and pharmacy graduate students emphasizing the issues involved in making the transition from inpatient to outpatient care.

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Find these studies (“Clinical hospital medicine fellowships: perspectives of employers, hospitalists and medicine residents” and “Post-discharge follow-up visits for medical and pharmacy students on the inpatient medicine clerkship”) in the January-February Journal of Hospital Medicine.

Patients often are overwhelmed by the change, and the situation is ripe for miscommunication and error. Students accustomed to seeing these individuals only in the hospital often underestimate the challenges patients confront when they leave the hospital with a bewildering array of instructions and medications.

Medical students also receive little exposure to the roles of caregivers from other fields, yet good transitional care involves professionals from several disciplines. The authors, led by Cindy Lai, MD, assistant clinical professor of medicine at UCSF, reason that “training students in interdisciplinary collaboration may improve their ability to provide quality care.”

They designed an inpatient medicine clerkship curriculum in which teams of medical and pharmacy students paid a home visit to a patient they had cared for in the hospital. After the visits, the students wrote summary letters to each patient’s primary care physician.

The home visits lasted one to two hours and in general consisted of an introduction to the patient’s living quarters, a review of symptoms and medication, a brief physical examination, and a home tour to check for relevant issues such as safety hazards or the patient’s ability to function independently. Students quickly discovered the visits consisted of much more than that.

“Across the board, the response that came back was the ability to view the patient as a person,” says Heather Nye, MD, PhD, assistant clinical professor of internal medicine and one of the authors of the study. Students found it inspiring to see patients as people in control of their surroundings and also were surprised how well or poorly some people did away from the hospital.

Dr. Nye

They learned how to maximize their interaction with the pharmacy students and how to anticipate problems patients might encounter at home, such as taking medicines appropriately or scheduling and keeping follow-up appointments.

Apparently, the lessons went both ways, with some patients inviting students to stay for dinner or dessert. “That human aspect was one of the most profound features of the visits,” Dr. Nye says.

She acknowledges that scheduling home visits regularly would require a commitment of time and money that is simply not feasible in today’s environment, especially after medical school. But she urged that instruction in transitional and interdisciplinary care be incorporated into the curriculum whenever possible. “We all understand that safe discharges require multiple disciplines,” she said. “It’s never too early to start teaching about transitional care.”

Medical school training is especially important because students and residents who specialize in hospital medicine will find fellowships in short supply. The few that exist function more to train educators rather than practicing physicians.

I was surprised at how strongly practicing hospitalists, most of whom are not academics, supported the value of an intense year of clinical hospital medicine fellowship training.

—Philip Goodman, MD, professor of internal medicine and biomedical engineering, University of Nevada, Reno, School of Medicine

This despite the fact hospital medicine has grown at a near-exponential pace, from 2000 practitioners in 1998 to 15,000 in 2005, with 30,000 projected by 2010.

Dr. Goodman

Practicing hospitalists and residents Philip Goodman, MD, MS, and Andrius Januska, BS, of the University of Nevada, Reno, School of Medicine set about to gauge the value of and interest in a practical fellowship in hospital medicine to employers. They sent questionnaires to employers and practicing hospitalists. Of 103 employers, two-thirds indicated they would offer fellowship graduates a signing bonus or salary premium ranging from $10,000 to more than $20,000.

Of 101 practicing hospitalists, 58% felt a clinical fellowship probably or strongly would be a good career move. Further, 91% said it would at least possibly be a good move. And 57% of the residents thinking of a career in hospital medicine said they would consider a one-year clinical fellowship if one were available.

“I was surprised at how strongly practicing hospitalists, most of whom are not academics, supported the value of an intense year of clinical hospital medicine fellowship training,” says Dr. Goodman, professor of internal medicine and biomedical engineering. “Most felt that graduating internal medicine residents ‘probably’ or ‘strongly’ should consider such fellowship training. I had expected a more neutral response, reflecting a balanced response bias of those with strong feelings at either extreme.”

Such training can offer new physicians a chance to develop expertise and leadership capabilities that might otherwise require years of on-the-job experience, he explains. Fellowship training also might elevate hospitalists to a level of prestige equaling that of other subspecialties, he says.

Ironically, the specialty’s rapid growth is probably slowing the establishment of fellowship programs, because residents can command annual salaries of $160,000 to $200,000 upon graduation with no special fellowship training. But a few months into it, they often realize a fellowship would have helped them master some of the unique aspects of hospital medicine, such as process of care, communication, productivity and medicolegal insight, and quality improvement, Dr. Goodman notes.

The University of Nevada will start training its first six hospitalist fellows next year. “I wouldn’t be surprised if most applicants were those who had recently taken hospitalist positions but realized the professional impact a year of polishing school can provide,” he says. TH

Norra MacReady is a medical writer based in California.

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