Interest in hospital medicine
“Throughout our medical training we do a variety of rotations and clerkships. I found myself falling in love with all of them – surgery, psychiatry, obstetrics, and gynecology,” Dr. Tuck explained, as he reflected on how he ended up in hospital medicine. “As someone who was interested in all of these different fields of medicine, I considered myself a true medical generalist. And in hospitalized patients, who struggle with all of the different issues that bring them to the hospital, I saw a compilation of all my experiences in residency training combined in one setting.”
Hospital medicine was a relatively young field at that time, with few academic hospitalists, he said. “But I had good mentors who encouraged me to pursue my educational, research, and administrative interests. My affinity for the VA was also largely due to my training. We worked in multiple settings – academic, community-based, National Institutes of Health, and at the VA.”
Dr. Tuck said that, of all the settings in which he practiced, he felt the VA truly trained him best to be a doctor. “The experience made me feel like a holistic practitioner,” he said. “The system allowed me to take the best care of my patients, since I didn’t have to worry about whether I could make needed referrals to specialists. Very early in my internship year we were seeing very sick patients with multiple comorbidities, but it was easy to get a social worker or case manager involved, compared to other settings, which can be more difficult to navigate.”
While the VA is a “great health system,” Dr. Tuck said, the challenge is learning how to work with its bureaucracy. “If you don’t know how the system works, it can seem to get in your way.” But overall, he said, the VA functions well and compares favorably with private sector hospitals and health systems. That was also the conclusion of a recent study in the Journal of General Internal Medicine, which compared the quality of outpatient and inpatient care in VA and non-VA settings using recent performance measure data.1 The authors concluded that the VA system performed similarly or better than non-VA health care on most nationally recognized measures of inpatient and outpatient care quality, although there is wide variation between VA facilities.
Working with the team
Another major interest for Dr. Tuck is team-based learning, which also grew out of his GWU leadership certificate course work on teaching teams and team development. He is working on a draft paper for publication with coauthor Patrick Rendon, MD, associate program director for the University of New Mexico’s internal medicine residency program, building on the group development stage theory – “Forming/Storming/Norming/Performing” – developed by Tuckman and Jenson.2
The theory offers 12 tips for optimizing inpatient ward team performance, such as getting the learners to buy in at an early stage of a project. “Everyone I talk to about our research is eager to learn how to apply these principles. I don’t think we’re unique at this center. We’re constantly rotating learners through the program. If you apply these principles, you can get learners to be more efficient starting from the first day,” he said.
The current inpatient team model at the Washington VAMC involves a broadly representative team from nursing, case management, social work, the business office, medical coding, utilization management, and administration that convenes every morning to discuss patient navigation and difficult discharges. “Everyone sits around a big table, and the six hospital medicine teams rotate through every fifteen minutes to review their patients’ admitting diagnoses, barriers to discharge and plans of care.”
At the patient’s bedside, a Focused Interdisciplinary Team (FIT) model, which Dr. Tuck helped to implement, incorporates a four-step process with clearly defined roles for the attending, nurse, pharmacist, and case manager or social worker. “Since implementation, our data show overall reductions in lengths of stay,” he said.
Dr. Tuck urges other hospitalists to pursue opportunities available to them to develop their leadership skills. “Look to your professional societies such as the Society of General Internal Medicine (SGIM) or SHM.” For example, SGIM’s Academic Hospitalist Commission, which he cochairs, provides a voice on the national stage for academic hospitalists and cosponsors with SHM an annual Academic Hospitalist Academy to support career development for junior academic hospitalists as educational leaders. Since 2016, its Distinguished Professor of Hospital Medicine recognizes a professor of hospital medicine to give a plenary address at the SGIM national meeting.
SGIM’s SCHOLAR Project, a subgroup of its Academic Hospitalist Commission, has worked to identify features of successful academic hospitalist programs, with the results published in the Journal of Hospital Medicine.3
“We learned that what sets successful programs apart is their leadership – as well as protected time for scholarly pursuits,” he said. “We’re all leaders in this field, whether we view ourselves that way or not.”
1. Price RA et al. Comparing quality of care in Veterans Affairs and Non–Veterans Affairs settings. J Gen Intern Med. 2018 Oct;33(10):1631-38.
2. Tuckman B, Jensen M. Stages of small group development revisited. Group and Organizational Studies. 1977;2:419-427.
3. Seymann GB et al. Features of successful academic hospitalist programs: Insights from the SCHOLAR (Successful hospitalists in academics and research) project. J Hosp Med. 2016 Oct;11(10):708-13.