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Is It Time to Be More Explicit About the Purpose of a Hospital Admission?

Goldszmidt, Mark, MD, PhD, FRCPC; Faden, Lisa, PhD; Baranova, Katherina

doi: 10.1097/ACM.0000000000002510
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Purpose Patient care suffers when teaching teams fail to achieve a shared understanding of problems to be addressed during a hospital admission. In academic contexts where attending physicians take turns supervising, practice variability may contribute to undermining this shared understanding. Exploring variability around what constitutes the purpose of the hospital admission was the focus of this study.

Method Constructivist grounded theory was used to inform data collection and analysis of this two-phase study, conducted in London and Hamilton, Ontario, Canada, in 2012. In phase 1, interviews with 24 attending physicians from 2 academic health centers were conducted. Phase 2 involved analyzing 18 audio-recorded admission case review discussions in relation to the emergent theory from phase 1. Participants for phase 2 were 7 different attendings, 7 medical students, and 5 junior residents.

Results Three dominant perspectives around the purpose of an admission were identified. The most focused perspective characterized the purpose as making patients ready for discharge. By contrast, the most comprehensive perspective characterized admission as an opportunity to identify ways to improve overall patient health status. The third perspective was in-between—treating acute issues while monitoring pertinent chronic conditions. All attendings expressed a sense of discharge pressure but responded with different strategies. Attendings rarely explicitly discussed their perspectives as part of case review.

Conclusions These extremes of practice and lack of overt dialogue are concerning. Potential effects include mixed messages to trainees and missed opportunities for dialogue and debate around what can and should be achieved during a hospital admission.

M. Goldszmidt is research scientist and associate director, Centre for Education Research & Innovation, and professor of medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

L. Faden is research specialist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

K. Baranova is a medical student, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

Funding/Support: This study was funded in part by the Academic Medical Organization of Southwestern Ontario (AMOSO) Innovations Grant Project R3381A06 and Program of Experimental Medicine (POEM), Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario Project R3381A03.

Other disclosures: None reported.

Ethical approval: Approved by the University of Western Ontario Health Sciences Research Ethics Board review no. 16823E, 2012.

Previous presentations: Results of an earlier interpretation of the work were presented as: Faden L, Goldszmidt M, Lingard L. Attending physicians’ implicit beliefs about the purpose of hospital admission: Implications for clinical teaching teams. Presented at: Canadian Conference on Medical Education; April 26, 2015; Vancouver, British Columbia, Canada.

Correspondence should be addressed to Mark Goldszmidt, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Health Sciences Addition Room 115, London, Ontario, Canada, N6A 5C1; telephone: (519) 858-5007; e-mail: Mark.Goldszmidt@schulich.uwo.ca.

© 2019 by the Association of American Medical Colleges