The attending physician on the general medicine “teaching” service is called from the Emergency Department regarding an elderly woman who presents after suffering sacral insufficiency and pubic rami fractures in a fall at home. The patient has experienced progressive cognitive and functional decline over the course of months accompanied by an increasing frequency of falls. At the time of presentation, the patient is unable to ambulate because of pain and is referred for admission to the medical service. The attending physician on the general medicine teaching service contacts a hospitalist to admit the patient to the “nonteaching” service.
A young man with an opioid use disorder has been hospitalized on the general medicine teaching service for two weeks with endocarditis related to intravenous drug use. His bacteremia had cleared, and a prolonged inpatient course for completion of intravenous antibiotics is planned. Despite objective clinical improvements, the patient continues to report significant pain and to request opioid analgesics. He is frequently confrontational with clinicians and nursing staff. The resident’s assessment and plan on teaching rounds include a recommendation for transfer to the nonteaching service.
The medicine services at many academic medical centers (AMCs) in the United States are divided into teaching services and nonteaching services.1,2 Recognizing great variability between institutions, teaching services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team and are led by a faculty physician. Nonteaching services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services may have different names at different institutions (e.g., “faculty service,” “nonhousestaff service,” “hospitalist service”), but “nonteaching service” continues to be the most common and universally understood name.
Although rigorous studies are lacking, anecdotal reports and survey data suggest that the volume of patients cared for on nonteaching services has grown markedly over the past 15 years.1 Regulations limiting resident duty hours and patient loads3,4 and efforts to enhance the educational environment have been major drivers in this growth, but operational considerations such as improving throughput and reducing length of stay have also contributed. The rise in nonteaching services has been paralleled by dramatic growth in hospitalist services deployed at AMCs—and many of the patients previously managed on teams with residents are now managed on teams with hospitalists and advanced practice providers.5
The methods for allocating patients to teaching and nonteaching services are likewise variable across institutions.6 Reported strategies for patient assignment include census caps, time of day, and geography, and these methods may be used alone or in some combination. For example, patients may be assigned to teaching service teams until a census cap is reached, and then “overflow” patients will be assigned to a nonteaching service. Alternatively, patients may be assigned to teaching or nonteaching teams based solely on the location of an available bed or the time of an admission.
One of the most common strategies, however, employs assignment to nonteaching services based on the perceived “teaching value” of a patient to medical learners. This strategy often results in patients with lower levels of clinical acuity assigned to the nonteaching service, while patients with higher levels of clinical acuity are assigned to the teaching services. As an example, at our institution, diagnoses such as severe low back pain, subacute or chronic progressive confusion, behavioral disturbance, functional decline, and nonoperative fractures are commonly assigned to the nonteaching services. Higher-acuity cases—particularly those requiring frequent testing, intensive interventions, and procedures—tend to be admitted to the teaching services. Patients may be transferred from the teaching services to the nonteaching services once the care acuity declines. For example, after initial treatment, patients who require long-term inpatient antibiotics or patients for whom discharge from the hospital is impeded by financial circumstances, care needs, or decisional capacity may be transferred to nonteaching services.
Although the creation of clinical services to manage patients without resident physicians is necessary to address regulatory requirements and offers the promise of an enhanced learning environment on traditional teaching services, the structure of nonteaching services at many AMCs has created unintended consequences. The allocation of patients to nonteaching services often lacks deliberate consideration of the educational and patient care objectives of residency programs and medical schools and may actually convey a hidden curriculum that undermines true curricular and care goals. The structure of some nonteaching services can paradoxically result in residents who are unprepared to manage the breadth of problems encountered in clinical practice, faculty who feel devalued, and suboptimal patient care. Even the term “nonteaching service” communicates values that are discordant with many of those we aspire to model and teach.
Lessons From the Nonteaching Service Experience
We share some lessons from observations of the nonteaching service models at our institution and other AMCs, and advocate for a thoughtful and measured reevaluation of the mission and structure of these services.
Lesson 1: The nonteaching service may not be serving learners
Allocating patients to teaching services based on perceived teaching value may result in significant gaps in clinical experience and knowledge for residents and students. Observational studies have shown disproportionate distribution of patients with various diagnoses between teaching and nonteaching services.7–9 Furthermore, Roberts et al7 surveyed medicine residents and hospitalists at one AMC and concluded,
Residents and faculty agreed that rare cases, patients with unique physical findings, and a variety of pathology were ideal for teaching services and that social admissions, benefactors, and patients with chronic or functional pain were not.
When disproportionate distribution of patients excludes specific diagnoses or categories of patients from teaching services, opportunities to educate residents and students about crucial topics in inpatient medicine may be missed. By excluding “social admissions” from the teaching experience, we may omit educating our learners about social determinants of health, disparities in health care, decisional capacity assessment, surrogate decision making, community services, payment systems, and the impact of policy on health care delivery. The common allocation of patients with chronic or functional pain to nonteaching services is particularly troubling—as chronic pain impacts more than 100 million patients in the United States10—and the inpatient management of severe and uncontrolled chronic pain would seem to be a core requirement for most modern inpatient medicine curricula.
The overlooked curricular areas undoubtedly differ between institutions, based on local customs for assigning patients to teaching and nonteaching services. In our experience, inpatient management of substance use disorders, frailty, and dementia frequently receives inadequate attention. For example, a new junior faculty physician in our Division of Hospital Medicine reported that, upon starting as an attending physician, he felt inadequately prepared to manage nonoperative fragility fractures in the elderly, predominantly because patients with these diagnoses had been admitted to the nonteaching service during his residency training experiences.
Lesson 2: Beware the hidden curriculum
Beyond the exclusion of specific content from the clinical curriculum, the allocation of patients based on perceived “teaching value” has the potential to convey attitudes, biases, and assumptions that directly contradict the stated and intended curricular goals. From the real-life examples at the beginning of this essay, an observant medical learner might appropriately conclude any of the following lessons:
- Higher intensity and acuity of care constitute “real medicine”;
- Testing and procedures are more important than communication and counseling;
- Continuity of care and longitudinal relationships are only spoken values;
- Addiction and chronic pain are not true “medical problems”;
- There is nothing to learn about cognitive and functional decline; or
- Socioeconomic factors are not important determinants of health.
The concurrence between residents and faculty on the elements that constitute an “ideal teaching admission,” as reported by Roberts et al,7 suggests that the hidden curriculum is effectively, if not overtly, transmitted to trainees. While most institutions unequivocally strive to prepare students and residents to provide comprehensive and compassionate care, the model of many nonteaching services may controvert this mission.
Lesson 3: The nonteaching service may not be serving attending physicians
The distribution of patients to nonteaching services based on diagnosis, acuity, or other categorization can lead to clinical experiences that lack the variety sought by many attending physicians who pursue hospital medicine or general internal medicine as a profession. In itself, this may result in low job satisfaction and high turnover—a common problem encountered by hospital medicine programs. Furthermore, in an AMC where teaching is esteemed, it is understandable how physicians who care for patients on the nonteaching service can feel undervalued. Indeed, this “value” deficit can likely be quantified in dollars, as it is customary that attending physicians who care for patients on the nonteaching services require higher compensation to recruit and retain than those who care for patients on the teaching services.
Lesson 4: The nonteaching service may not be serving patients
There is a surprising paucity of recent data about the comparative quality of care delivered on teaching and nonteaching services. Roy et al11 described a physician assistant/hospitalist service model in an AMC and found no significant differences in length of stay, inpatient mortality, intensive care unit transfers, readmissions, or patient satisfaction when compared with traditional teaching services. Au et al12 conducted a systematic review and meta-analysis and found no differences in inpatient mortality and 30-day readmission rates between general internal medicine patients admitted to teaching and nonteaching services between 1987 and 2011. Most of the studies included in this systematic review were low-quality observational studies with high risk of allocation bias due to the methods used for assigning patients to the teaching or nonteaching services.
Certainly, comparing quality of care between teaching and nonteaching services is challenging for most institutions. Differential assignment of patients results in distinctly different patient populations and makes it difficult to interpret differences in quality measures and patient experience scores between teaching and nonteaching services. Some nonteaching services are designed with the expectation of delivering care to lower-acuity patients, and thus physician-to-patient ratios may be significantly lower on some nonteaching services. Handoffs and sign-out processes may also differ dramatically between teaching and nonteaching services. Finally, transitions of patients between teaching and nonteaching services may further fragment care and complicate attribution of patients when assessing quality.
Considerations in Designing Nonteaching Services
We anticipate that efforts to balance resident workload in an environment of limited residency slots and expanding clinical needs of an aging population13 will continue to drive development and growth of nonteaching services in AMCs. As AMCs introduce, expand, and evolve nonteaching services, we propose a number of principles for consideration and debate:
- Enumerate and prioritize educational and patient care objectives and purposefully design nonteaching services to meet those objectives. Ensure that the nonteaching service structure reflects the core values of the educational programs.
- Minimize assignment of patients based on perceived teaching value. Use allocation methodologies that promote efficient, effective, longitudinal, patient-centered care. This will likely result in similar patient populations on the teaching and nonteaching services and will require adequate round-the-clock staffing of the nonteaching service to manage a full spectrum of acuity in the absence of resident physicians.
- Intentionally incorporate clinical experiences and education on the teaching service to address the broad spectrum of clinical conditions encountered in the hospital, including frailty, dementia, behavioral health, addiction medicine, chronic pain, and nonoperative fractures. Use the opportunity of a full spectrum of patients to teach about communication skills, social determinants of health, health literacy, health disparities, health care policy, and payment systems. This may require the development of faculty with expertise in these areas. Establish competencies for students and trainees in these domains and monitor progress over time to ensure that the range of programmatic objectives is met.
- Promote satisfaction and retention among attending physicians who cover the nonteaching service. Provide attending physicians who cover the nonteaching service opportunities to care for a diversity of disease entities and acuity, to interact with learners, and to engage in quality improvement and other scholarly activities. Recognize outstanding patient care, communication skills, contributions to patient safety, and other accomplishments of the attending physicians on the nonteaching service.
- Create a learning environment on teaching and nonteaching services alike. Unusual exam findings, rare diagnoses, and diagnostic or therapeutic dilemmas can be shared across services through physical exam rounds, morning report, morbidity & mortality conferences, or other academic venues.
- Assess differences in care delivery across the teaching and nonteaching services, and use the parallel structures to introduce and rigorously evaluate quality improvement and patient safety efforts, with the goal of integrating best care processes across all services and generating scholarship in improvement science.
- Finally, rename the nonteaching service. “Nonteaching” service assigns a pejorative label to the patients and clinicians who care for them. Regardless of the presence or absence of resident physicians on the team, we have an obligation to create an environment where we can learn from our patients and from each other.
One might imagine a future where an “assignment optimization system” uses complex algorithms to allocate patients to clinical services—matching curricular and competency needs for specific learners to individual patient profiles—all while balancing workloads and enhancing the quality of care and patient experience. In the absence of such a system we hope that these practical proposals will advance education for students and residents, promote professional satisfaction for attending physicians, and enhance the quality and experience of patient care. We recognize that some AMCs have already adopted many, if not all, of these principles into the design of their nonteaching services. We encourage further conversation and publication about the successes and pitfalls of these approaches.
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