Hospitalist physicians as educators in a community hospital: the trainee's view.

To the Editor: Hospitalists are playing an increasing role in inpatient care. In teaching institutions, hospitalists supervise patient care and participate in teaching conferences for residents. (1) This educational role is well established in university hospitals where residents prefer teaching by hospitalist physicians over General Medicine Unit (GMU) physicians. (2,3) That success, however, has not been well studied in community hospitals. In an attempt to explore this in community hospital settings, we surveyed whether residents obtain a better educational experience by caring for hospitalist-served patients or community physician-served patients.

We surveyed 38 residents training in our internal medicine residency program. Residents work under the supervision of a hospitalist for one month and spend four months each year on traditional floor teams. Each resident team consists of an intern and a resident. On traditional floor teams, residents care for patients admitted under community attending physicians. These attending physicians are expected to discuss the management of their patients with the residents. Didactic/clinical teaching rounds, which are distinct from patient management, are held by GMU physicians for those teams. Traditional floor teams may often care for hospitalist-served patients, too. While in the hospitalist rotation, one identified hospitalist physician works with one resident team, combining management and teaching rounds. We asked residents to rate each experience (serving hospitalist versus traditional attending patients) using a 12-point questionnaire, which was prepared from the ACGME evaluation form (http://www.acgme.org). Attendings were rated on a 5-point scale (1 = poor, 5 = superior). We excluded the GMU physicians from this survey. Responses were confidential. We used at test to compare the outcome variables.

Thirty of the 38 residents (78%) returned the survey. Residents felt that hospitalists showed more enthusiasm in teaching (P = 0.01) and were more available to the residents for teaching (P = 0.002). Hospitalist physicians practiced evidence-based medicine better than community-based attendings and emphasized cost-effective care (P = 0.01). There was no difference between the groups in ethics-based practice and in providing opportunities to the residents to perform procedures (P = 0.06, P = 0.195). Overall, for teaching effectiveness, hospitalists had an average score of 3.83 versus 3.07 for community attendings (P = 0.007). Seventy-three percent of the respondents preferred to work under hospitalists in the future in contrast to 13% who preferred community attendings.

This survey demonstrates that residents perceived a better learning experience by caring for hospitalist-served versus community physician-served patients. Earlier studies in university settings showed hospitalist physicians as better educators than GMU attendings employed by the university and who have protected teaching time. (2,3) Unlike our study, community-based physicians were not compared with hospitalists in prior studies. Residents felt easy availability, enthusiasm and the practice of evidence-based medicine by hospitalist physicians were valuable teaching experiences in the residency program. The residents' overwhelming preference for hospitalist supervision prompts a detailed comparison of the overall learning experience gained from rotations with hospitalists versus community/GMU physician combinations in community-based residency programs.

Sankar D. Navaneethan, MD, MPH 

Amit Nautiyal, MD

Khalid Abdel-Gadir, MD

Rakesh Shrivastava, MD

Ganapathi Parameswaran, MD

Michael R. DiSalle, MD

James Haley, MD

Department of Medicine

Unity Health System

Rochester, NY

References

1. Meltzer D, Manning WG, Morrison J. et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med 2002;137:866-874.

2. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med 2004;164:1866-1871.

3. Hunter AJ, Desai SS, Harrison RA, et al. Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations. Acad Med 2004;79:78-82.