In traditional teaching hospitals, the structures of teaching and patient care vary somewhat between institutions, but in every setting the attending physicians' participation in issues related to management of patients and teaching of housestaff and medical students is balanced.1 Careful documentation of patients' status is an important aspect of patient care and is also a valuable teaching exercise for medical trainees. In many teaching hospitals where the work of documentation has been managed, at least in part, by trainees, attending physicians have had more time to devote to teaching and supervision. This division of labor was challenged by the Health Care Financing Administration (HCFA) Teaching Physician Rules regarding documentation of physical presence that went into effect in 1996.2 The most stringent interpretation of these guidelines requires the attending physician to perform a daily examination of the patient and extensive documentation of findings. In hospitals where the inpatient service's attending physician is responsible for patient care, billing, documentation, and housestaff education, these guidelines are often viewed as time-consuming and cumbersome.3
Attending physicians at teaching hospitals have responded to these guidelines in various ways. Some examine patients and perform all documentation and billing requirements before or after teaching rounds. Others have not been excused from clinical responsibilities that previously occupied time outside teaching rounds, so they attempt to meet the increased physical-presence requirements during teaching rounds, and some also attempt to meet documentation requirements during teaching rounds. Some attending physicians may manage variations of this process effectively and efficiently, but many residency program directors and residents are concerned about the impact of the new guidelines on the residents' overall education.
Recognizing that the new HCFA guidelines could affect the quantity and quality of the housestaff's education on inpatient services, the chief medical residents held informal meetings with small groups of housestaff to discuss their perceptions of attending physicians' teaching. Four major impediments to teaching by attending physicians were commonly cited: attending physicians' clinic responsibilities, teaching style, billing and documentation requirements, and the number of patients on the service (inpatient census). As a result of these meetings, a formal survey was developed to quantify the amount of teaching residents perceived to be occurring on each service and to assess the relative impact of the commonly cited impediments on the quantity and quality of teaching by attending physicians on our inpatient medical wards.
The study took place in 1998 at our 600-bed university teaching hospital located in an urban area. There are 200 internal medicine beds covered by 40 housestaff at any given time. The housestaff in the study spent 20 months during their three-year residency on five different inpatient services. They were supervised by 133 of the 200 full-time faculty from the department of medicine.
Within the department, it is expected that attending physicians on inpatient services provide didactic teaching that is separate from direct management issues. Each inpatient service utilizes a different organizational structure in an effort to facilitate patient care and housestaff education. On some services attending physicians perform billing and documentation during teaching rounds, while on other services attending physicians perform these tasks outside teaching rounds.
The chief residents and program director meet regularly with members of the medicine housestaff to discuss issues that are pertinent to the housestaff's training. In 1998, these discussions revealed four recurring issues affecting teaching on the inpatient services: clinic responsibilities for the teaching attending physicians that limited time for teaching rounds, the service's inpatient census, attending physicians' teaching styles and methods, and time spent by attending physicians trying to meet billing and documentation requirements. We developed a seven-page questionnaire to quantify the relative impacts of these specific issues on teaching by attending physicians.
The questionnaire was distributed to 92 house officers in internal medicine, medicine—pediatrics, and other departments where housestaff rotate for at least seven months on internal medicine services. Housestaff in postgraduate years one to four were included. The questionnaire was broken down into five sections, and each section contained questions about one of five inpatient services. Housestaff answered questions about only those inpatient teaching services on which they had rotated.
First, the housestaff were asked to estimate the amount of teaching by attending physicians on each service (hours per week). “Teaching” was defined as lectures, didactic teaching by the service's attending physician, and bedside instruction. Next, respondents were asked to rank four options in order of their being most detrimental to least detrimental to the total quantity of teaching: (1) attending physicians' billing and documentation, (2) attending physicians' clinic responsibilities, (3) attending physicians' teaching style, and (4) service's inpatient census. The same options again were ranked in order of most detrimental to least detrimental to the overall quality of teaching. Finally, respondents used a five-point Likert scale to rate the overall quality of teaching (independent of quantity) by attending physicians on each inpatient service.
The housestaff's response rate was 100% (92/92). Their perceptions of the quantity of teaching by attending physicians varied considerably among the five services (as illustrated in Table 1).
Figure 1 shows that billing and documentation requirements were identified by 39% of the housestaff as the major detriment to the quantity of teaching by attending physicians on inpatient services, as compared with 13% for clinic responsibilities, 20% for teaching style, and 28% for patient census. Thirty percent of the housestaff rated billing and documentation requirements as the major detriment to the quality of teaching, compared with 7% for clinic responsibilities, 46% for teaching style, and 16% for patient census.
Table 1 also shows the percentages of respondents who rated billing and documentation as most detrimental to quantity of teaching according to service. There is a significant amount of variability between services in the housestaff's responses. In the intensive care unit (ICU), only 7% of housestaff rated billing and documentation as the main detriment to quantity of teaching by attending physicians. However, 68% of housestaff cited billing and documentation as the main detriment to quantity of teaching in hematology/oncology.
The housestaff's ratings of the quality of teaching are also presented in Table 1. Overall, teaching was deemed to be very good or outstanding by 77% of the housestaff (data not shown). Again, however, there was significant variation between the individual services. A total of 99% of housestaff rated teaching by attending physicians as very good or outstanding on the ICU service, compared with 88% on general medicine, and 46% on the hematology/oncology service.
The results of this study indicate that billing and documentation requirements are perceived by housestaff to be a major detriment to the quantity of teaching on inpatient services, especially when faculty attempt to meet these requirements during teaching rounds. In addition, these requirements may have an important negative impact on the quality of teaching. In general, the housestaff at our institution perceived more hours of teaching on services where documentation occurred outside teaching rounds for housestaff. Additionally, those services on which attending physicians met billing and documentation requirements during teaching rounds received lower ratings for overall quality of teaching compared with the other services.
Attending physicians must adapt to the new billing and documentation requirements mandated by HCFA while trying to balance high-quality patient care and high standards of medical education. They are attempting to accomplish this during a time when teaching hospitals are facing unprecedented financial pressures.6,7,8 This study did not include measures of financial viability for the various services, but financial issues undoubtedly remain an unavoidable influence on how some attending physicians must structure their teaching time. Nevertheless, teaching institutions must give effective teaching priority despite these and other important influences.
An important extrapolation of these data is the effect of these issues on medical students' education. Third- and fourth-year medical students are important members of our medical teams and derive a significant portion of their education from attending physicians. It is likely that medical students' perceptions of the impact of billing and documentation requirements on teaching would be similar to those expressed by the housestaff in this study.
There are several limitations to this study. The questionnaire offered only four options for possible detriments to quantity and quality of teaching. Other important factors affecting teaching would not have been recognized.4,5 However, the four issues that were investigated were the issues most commonly cited during discussions with housestaff regarding teaching on inpatient wards. Also, no comparison data regarding the impacts of these factors on teaching are available for the period prior to adoption of the new HCFA documentation guidelines. However, concerns about attending physicians' billing and documentation requirements during rounds were never mentioned by housestaff in their evaluations of teaching prior to implementation of the mandated HCFA guidelines. Finally, this study was performed in a single university-based teaching program, and the results may not be generalizable to other settings.
Finally, it is important to note that housestaff are cognizant of the impact of attending physicians' billing and documentation requirements on the quantity of teaching, but they were more likely to rate teaching style as the major detriment to the quality of teaching. This should be an important reminder that teaching faculty should remain focused on effective methods for teaching and resist being discouraged or distracted by intrusive external forces.
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