In their Perspective in this issue, Repp and colleagues1 discuss the allocation of patients to teaching and nonteaching services. They “describe how the structure of ‘nonteaching’ services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of [academic medical centers].” Neither we nor Repp and colleagues are suggesting a retreat from the strategy represented by the nonteaching service, but, as they say, it is what it is.
The nonteaching service is a first step, and as Repp and colleagues correctly point out, an imperfect step, toward enabling the inpatient teaching service to transition from an unregulated, natural state, driven solely by the exigencies of patient volume and throughput, to one that is more controlled and intends to achieve the proper balance between service and education. However, the problem with the concept of the nonteaching service is not, as Repp and colleagues suggest, that it goes too far but, rather, that it has not yet gone far enough. If the nonteaching service and the teaching services are intended to be complementary, collaborative, and integrated components of a single system, we still have a long way to go.
How long a journey are we suggesting? How about all the way to the ideal state where all patients (teaching-service and nonteaching-service patients alike) receive the best possible care and all learners participate in the most valuable educational experience? All the way to a utopian teaching service. What would this look like? We cannot say for sure, but between us we have 60 years (a lifetime) of experience with inpatient teaching and operations, so indulge us in this utopian vision. Here we describe first the context, or setting, that would support this utopian teaching service. We then describe the participants, because only with trained faculty and motivated learners would such a service be possible. Next we explore the curriculum, which really defines the service’s goals and intentions, and then we depict how the participants in this service go about their work. Finally, we speculate on the synergistic relationship between this service—the utopian teaching service—and its complementary nonteaching service within the same institution.
A Utopian Teaching Service: The Clinical Learning Unit
Leaders at this institution explicitly acknowledge medicine’s contract with society to transform health care delivery. They acknowledge the role they have played in creating an environment focused on clinical volume, resulting in work compression and increasing intensity that has led to record levels of burnout amongst physicians. They appreciate that education, just like medical care, increasingly needs to demonstrate that it is providing value, which requires an understanding of its costs and the outcomes it produces and how new approaches might better achieve the goals.
Leaders at this institution believe that medical education is a type of implementation science and that only through rigorous evaluation will we understand the attributes of the clinical and learning environments that promote patient-centered care. They understand that our training programs must adopt shared responsibility for eliminating low-value care and promoting stewardship of our nation’s health care resources, especially given the evolving data showing that intensity of practice patterns are established during residency and persist for decades.2
Leaders at this institution appreciate that the continuum of education requires a continuum of teachers, so they protect time for faculty development in areas such as curriculum development and delivery, feedback, and evaluation.3 At this institution, participation in robust faculty development is a minimum expectation for maintaining a faculty appointment and working with trainees.
The current two-pillar model of clinical and basic sciences in the curriculum has evolved into an interdependent framework of basic, clinical, and systems science.4 The concept of basic science has been redefined to include sciences that support effective collaboration, such as clinical informatics, human factors engineering, economics and financing, safety, leadership, bioethics, etc. Clinical science has expanded to include the skills needed to effectively manage a patient encounter but also advanced skills in decision making, the use of technology, evidence-based medicine, behavioral change, and a framework for analyzing moral dilemmas, as well as recognizing conflicts and unconscious bias. Systems science provides the skills necessary to work within systems such as team training, interprofessional education, and the use of data to assess quality, safety, and value in the local clinical microsystem.
The team consists of an attending, an intern, an upper-year resident, a medical student, an advanced practice provider (APP), a group of primary nurses, a social worker, a case manager, a clinical pharmacist, and an analyst. The team is geographically localized to one floor in the hospital and is assigned to eight beds on the floor. Each pod of eight makes up a Clinical Learning Unit (CLU). This is a highly functioning team with embedded metrics managed by the analyst that align with institutional and national quality and safety goals. The analyst is trained in direct observation and performance measurement to enable rapid-cycle innovation and improvement.
The attending is a highly experienced general internist who has won several teaching awards and has participated in faculty development to enhance her skills in delivering feedback, direct observation, and bedside teaching. She belongs to a teaching academy that serves as a forum to share challenges and best practices. Given her accomplishments as a clinical teacher, she was selected by the medical school to serve as a longitudinal preceptor for a medical student entering clinical training. The student spends one full day per week with her for the entire year, except when she is on service—a period when the student is with her every day. She relishes her time on service with trainees, as she feels a tremendous commitment to training the next generation of physicians. She considers the experience invigorating and in no way a chore. She has no other clinical duties when assigned to this service, so she is always around for the supervision necessary for the task at hand.
The intern and resident are on the service for one month. They care for patients of other general internists in the practice as well as patients with undifferentiated complaints from the emergency department (ED). They each rotate through the general medicine outpatient practice one afternoon per week to see patients that they previously discharged or those presenting for urgent visits.
The APP is the institutional memory for the CLU. He orients the interns and residents as they come on the service. He is adept at invasive bedside procedures and is often supervising the interns’ and residents’ procedures. He manages the transitions program for this team to help keep patients from being readmitted. He also cares for the primary patients when the intern or resident is off.
Mr. Jones is a 76-year-old male with a history of coronary artery disease and type 2 diabetes mellitus. He has never smoked. He was well until three months ago when he began developing progressive dyspnea on exertion. His daughter sends him to the ED where he is ruled out for myocardial infarction (MI) and called in for admission to the CLU. The resident receives a call from the ED at 10 AM and takes the intern and the student to see the patient. They perform a complete history and physical exam. The patient has a normal cardiac exam and mild wheezing with a prolonged expiratory phase. They then call the social worker and the floor nurse, who arrive to participate in a social intake evaluation with the patient and his daughter, who participates through a video conference call. As a group, they summarize the plan of care, which includes an empiric trial of bronchodilators, a chest x-ray (CXR), and spirometry. The student accompanies the patient to his studies and then to the floor. The student carefully reviews all of the information in preparation for attending rounds at 1 PM. The team rounds at 8 AM, 1 PM, and 5 PM each day for, at most, 90 minutes. The goal is to advance the care plan of each patient at each rounding interval.
At 1 PM, the team gathers at the bedside of Mr. Jones and connects via a media wall to his daughter in another state. The student presents his case. The nurse adds her intake assessment and her concern that the patient’s gait is unstable and he has trouble following directions. The clinical pharmacist notes that he has been using multiple different pharmacies and has different dosages of insulin at home. The social worker adds that she is concerned about his driving given his trouble remembering how to get places. The analyst presents a comprehensive health care utilization report that shows this is his fourth admission in three months for the same complaint. Each time he was ruled out for an MI and treated for chronic obstructive pulmonary disease (COPD) with different combinations of inhalers, which he has not been using; indeed, his prescriptions have not been filled. He was never out of the hospital long enough to have outpatient follow-up. The team discusses his CXR and spirometry and agrees that he has obstructive lung disease. He has never smoked.
The attending now begins to ask some questions: Was he a full-term baby? Yes. Hospitalized as a child for respiratory diseases? No. Did people smoke in his home as a child? Both of his parents smoked heavily. Did he use coal or wood to heat his home as a kid? They used a wood-burning stove until he was 16 years old. The team now understands that he has COPD likely due to passive tobacco and biofuel exposure that often does not manifest until later in life. The student reviews the evidence-based guidelines for COPD and recommends a treatment regime. The pharmacist and social worker note the expense of some newer drug combinations and recommend less expensive alternatives. The plan of care moves from medical treatment of his COPD to management of him as a person.
The daughter has been listening all this time, appreciative of the time the team spends on her father. She finally understands the complexity of what he is going through. The patient is discharged to a skilled nursing facility (SNIF) with the goal of going to live with her. His discharge is complex and takes longer than his admission to process. Once he is ready to go, the resident notifies the team to attend the discharge huddle. The team assembles at the patient’s bedside again with his daughter linked in. The resident reviews the medical treatment plan and notes that he will see Mr. Jones in five days in the general medical clinic. Mr. Jones will become part of the resident’s virtual patient panel and will participate in a video call management session weekly under the direction of the attending physician. The social worker reviews the expectations for SNIF transfer and then home services. The pharmacist reviews the medications and associated co-pays. The nurse completes the package with patient and caregiver education. The transport arrives to pick up Mr. Jones, and his bed is cleaned, paving the way for another admission.
The day is now over. The team has engaged deeply in experiential learning. This was possible, however, only because the team had a manageable census, time for daily reflection, and meaningful relationships with trained teachers. In the CLU, every case is a substrate for teaching. Workload is measured in not only the census of the team and the number of admissions but also the number of discharges, transfers, and follow-ups allowing for an accurate picture of work intensity.
The utopian nonteaching service
The CLU, or our utopian teaching service, cannot exist in a vacuum. There are just too many patients. There must be services without trainees—nonteaching services—that parallel CLUs. Surely, on a parallel nonteaching service, a group of APPs or licensed physicians could take the places of the trainees on our utopian service. The patient care goals between teaching and nonteaching services should be identical, as should the commitment to clinical and systems science. The institution’s values must be reflected in both models. The only difference is that a CLU is training tomorrow’s health care workforce through adaptive service learning.
Taking a First Step Toward Utopia
Repp and colleagues identify seven design principles for nonteaching services.1 We believe these principles are a good place to start on the journey toward the utopia we’ve described here, and we highlight principle 7 in particular, which suggests renaming nonteaching services. Adding the prefix “non” was a simple naming convenience years ago when such services needed to be differentiated from teaching services. A more appropriate label might be Collaborative Care Services. Without them, we cannot even come close to utopia. Whatever we call them, they are absolutely essential to training the next generation of providers.