The integration of the hospitalist in the care of inpatients has become widespread since the appearance of hospitalists as a care-delivery strategy in 1996.1,2 Hospitalists are physicians who spend greater than 25% of their professional time being the physician of record for inpatients and ultimately return these patients back to the care of the patient’s primary care physician.1,2 The impact of hospitalists on medicine in the United States has been described in economic, clinical, and educational domains.1,3–5 Studies have explored benefits related to the fiscal operations of health care systems,6–13 the impact on patient satisfaction, continuity of care,9,12,14,15 and housestaff education.6,10,16 Although opinions and perspectives exist, absent from the literature are any research descriptions of the impact of hospitalists on medical student education.
In 1995, our Department of Medicine and residency program recognized a progressive decline in medical student and housestaff satisfaction with the educational experiences on the university hospital inpatient rotation. To a large extent, this was attributed to reductions in faculty availability due to increasing clinical and research demands. In response, the Department of Medicine established a hospitalist program with the initial goal of improving housestaff and medical student education. At the end of the first year of operation, as part of an internal quality assessment of the program, we identified some interesting trends in the student evaluations of hospitalist faculty and embarked on further evaluation.
The purpose of this study was to formally assess the impact of hospitalist teaching faculty on the experiences of medical students on their inpatient medicine rotations, as compared to the impact of highly rated nonhospital-based teaching faculty.
We performed a retrospective analysis, comparing third-year medical student evaluations of hospitalist and nonhospitalist ward faculty on their inpatient medicine clerkship rotations.
Setting and Sample
We conducted our study at the 397-bed tertiary-care University Hospital affiliated with Oregon Health & Science University School of Medicine, in Portland, Oregon. Before the formal establishment of the Hospitalist Program in 1998, the university inpatient housestaff teams were staffed by a variety of models. In 1995, based on housestaff evaluative data, such as overall performance, availability and consistency, the number of faculty members was reduced from 51 to 22. In 1998, the Hospitalist Program was formed with six hospitalists staffing 34 to 36 out of 48 months, on one-month rotations. Faculty members from the previously selected attending pool staffed the remaining months.
Full-time hospitalists at our institution attend six months on the inpatient teaching wards and spend three months on a general medicine consult service. During their inpatient rotations, hospitalists are expected to maximize their clinical revenues with complete medical documentation; participate in committees, educational conferences, and in the medical school and intern selection process; and staff an ambulatory clinic one-half day per week. Eleven “nonhospitalists” and three chief medical residents staff the remaining ward months. The nonhospitalist faculty was outpatient based, and had been selected based on previous favorable housestaff feedback and program review. The chief residents attended a total of three months per year, but were considered to be fourth-year residents, and thus were not included in our analysis of faculty evaluations. We analyzed student evaluations comparing hospitalists and nonhospitalists, for the 1998–00 academic years. Data on demographic characteristics were not collected for medical students, but were obtained for the faculty members from our faculty database. The ward model in place during our study consisted of four general medicine inpatient teams, each with one faculty attending, one resident, and one intern. Three teams have one to two third-year medical students whereas one ward team does not have third-year medical students. Third-year medical students receive 12 weeks of internal medicine training and elect to spend six weeks of those either at the university hospital or the affiliated Veterans Affairs Medical Center. The other six weeks is spent at a community-based hospital. The medical student can request the rotation site, but the medical student clerkship office designates team and faculty assignments without student input.
Medical students submit a numeric and qualitative evaluation of each attending they work with at the completion of each of their clerkships (see Table 1). The evaluation forms were created locally, and are loosely based on the work of Skeff et al.17 Faculty were evaluated numerically on a nine-point Likert-type scale (1 = poor; 9 = outstanding) on the following characteristics: communication of rotation goals, establishing a favorable learning climate, use of educational time, teaching style, evaluation and feedback, and two general assessments (contributions to the student’s growth and development, and overall effectiveness as a clinical teacher). Faculty may not review students’ evaluations of them before completing their evaluations of the students. The initial project, data collection, and analysis were part of an internal quality assessment, which later developed into an educational then scholarly focus. Thus, we obtained Institutional Review Board review and endorsement after completing the project.
Statistics and Analysis
At our institution, students’ numeric evaluations of faculty are skewed toward the high end of the Likert-type scale (7–9 on the nine-point scale). Because of this non–bell-shaped response distribution, we analyzed group results using (nonparametric) Mann-Whitney rank sum tests for numeric variables and Fisher exact test for dichotomous variables. All reported p values are two-sided. An administrative assistant not involved in the study entered primary data. We did not review the original evaluations and only viewed aggregated data.
Demographic characteristics of the hospitalist and nonhospitalist faculty evaluated in our study are shown in Table 2. Hospitalists were all general internists who graduated more recently from training programs (4.2 years versus 10.9 years, p = .034) and staffed the inpatient service more months per year then did the nonhospitalist faculty (p < .001). Hospitalists were more likely to be recent graduates from training programs, even with one of them having been in practice for 22 years (p = .034). The nonhospitalists were mostly general internists and a few subspecialists. There were no differences in age, gender, academic rank, specialty, or whether they had a formal role in education.
A total of 138 students rotated on the university wards during the study period; 100 with the hospitalists, and 38 with the nonhospitalists. Of these students, 99 (71.7%) returned evaluations (see Table 3). We reviewed data from all 99 evaluations. There was no statistical difference in the percentage of submitted medical student evaluations when we compared evaluations of hospitalists (72.0%) to evaluations of nonhospitalists (71.1%, p = .912). The hospitalists received higher numeric evaluations for all individual attending characteristics (see Table 3). Of these, statistical significance was demonstrated when we compared communication of rotation goals (p = .011), effectiveness as a clinical teacher (p = .016), and for the combined analysis of all parameters (p < .001). There was no significant difference between hospitalists and nonhospitalists when we looked at learning climate, use of educational time, teaching style, evaluation and feedback, and contributing to the growth and development. Evaluation results did not differ significantly among hospitalists.
Academic hospitalists constitute the minority of hospitalists in the United States,2 yet they have great potential to affect medical trainees at all levels.3–5 Although others have evaluated the impact of hospitalists on resident perceptions of education,5,10,18–21 we present the first discussion of medical student assessment of hospitalists as teachers in a university-based inpatient clerkship rotation.
Our study demonstrates that in addition to performing the responsibilities required of a full-time hospital-based physician, hospitalists in our program were able to provide at least as positive an educational experience as did highly rated nonhospitalist teaching faculty. Medical students felt the hospitalists were more likely to communicate clear goals for the rotations, and to demonstrate favorable skills as clinical teachers. Numerous factors may have contributed to the increased student satisfaction. First, because of the nature of their job description and departmental support for teaching, the hospitalists were more likely to be available in the afternoons, and thus may have had more contact time with students. Students may have favorably perceived this increased availability. Second, hospitalists were selected based on their enthusiasm for teaching which may have been evident to student learners. Although all the hospitalists were selected based on their interest in teaching, our results were reassuring because the nonhospitalist faculty were already viewed as highly effective and respected teachers.
The most significant limitation of our study was that it was retrospective and conducted at a single institution. Although these limitations raise questions of broader applicability, we believe that the initial observations are likely not unique and can likely can be applied on a broader scale. Based on the study design, there may have been several biases affecting the results. First, because one of the core objectives of the hospitalist program was to improve the educational experience of our trainees, this focus on education may have favored the hospitalists. Although this may be true, we also believe this is one of the strengths of our program and faculty. This potential bias was likely mitigated to some degree since the nonhospitalist faculty had already been selected based on their strong performance as educators. We believe this only strengthens the conclusions of our study. Third, the students’ selection of the university rotations was nonrandom, but because individual faculty assignments were made independently of student preferences, there was likely no response bias. Finally, our study more accurately reflected an evaluation comparing academic hospital-based physicians to academic nonhospital-based physicians, and, thus, our results may not be generalizable for evaluating a private staffing model that employs hospitalists.
In conclusion, there continues to be scant literature exploring the impact of hospitalists on medical students’ experience on inpatient rotations. Future evaluation should be conducted to reproduce our findings as well as to assess the impact of hospitalists on measurable knowledge and skills outcomes, not just learner satisfaction; and to assess the impact of increased faculty (hospitalist) presence on the autonomy and decision making of learners. Our study provides early evidence that hospitalists can provide as positive, and maybe better, educational experiences to medical students on inpatient internal medicine rotation, as do traditional highly-rated nonhospitalist faculty.
The authors would like to thank D. Lynn Loriaux, MD, (chairman, Department of Medicine, Oregon Health & Science University) for essential support and review of the manuscript, and John Benson, MD (dean, emeritus, Oregon Health & Science University School of Medicine), Donald E. Girard, MD (associate dean for graduate medical education, Oregon Health & Science University), Gordon Noel, MD (chief medicine service, Portland Veterans Affairs Hospital) and Judith A Bowen, MD (chief, Division of General Medicine and Geriatrics, Oregon Health & Science University) for critical appraisal, advise, and counsel.
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