Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians

Outcomes on an inpatient oncology service after the introduction of hospitalist comanagement

BACKGROUND

Smilow Cancer Hospital (SCH) introduced hospitalist comanagement to the inpatient oncology service to address long lengths of stay and oncologist burnout.

OBJECTIVE

To determine the impact of hospitalists on inpatient quality outcomes and oncologist experience.

INTERVENTIONS

Hospitalists were introduced to one of two inpatient oncology services at SCH. Patients were assigned to teams equally based on capacity. Outcomes on the oncologist-led, traditional service (TS) were compared with outcomes on the hospitalist service (HS) 6 months after program implementation.

MAIN OUTCOMES AND MEASURES

Outcomes included patient volume, length of stay (LOS), early discharge, discharge time, and 30-day readmission rate. Mixed linear or Poisson models that accounted for multiple admissions during the study duration were used. Oncologist experience was measured by survey.

RESULTS

During the study period, there were 713 discharges, 400 from the HS and 313 from the TS (p = .0003). There was no difference in demographics or severity of illness (SOI) between services. Following adjustment for age, sex, race/ethnicity, cancer type, and discharge disposition, the average LOS was 4.71 on the HS and 5.47 on the TS (p = .01). Adjusted early discharge rate was 6.22% on the HS and 2.06% on the TS (p = .01). Adjusted mean discharge time was 3:45 p.m. on HS and 4:16 p.m. on TS (p = .009). There was no difference in readmission rates. Oncologists reported less stress (p = .001) and a better ability to manage competing responsibilities (p < .0001) while working on the HS.

CONCLUSIONS

Hospitalist comanagement significantly improved LOS, early discharge, time of discharge, and oncologist experience without an increase in 30-day readmissions.

Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients

BACKGROUND

The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins.

METHODS

A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System.

RESULTS

11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively.

CONCLUSIONS

Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.

A resident-created hospitalist curriculum for internal medicine housestaff

The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016;11:646-649. © 2016 Society of Hospital Medicine.

Associations between teaching effectiveness scores and characteristics of presentations in hospital medicine continuing education

BACKGROUND

There is little research regarding characteristics of effective continuing medical education (CME) presentations in hospital medicine (HM). Therefore, we sought to identify associations between validated CME teaching effectiveness scores and characteristics of CME presentations in the field of HM.

DESIGN/SETTING

This was a cross-sectional study of participants and didactic presentations from a national HM CME course in 2014.

MEASUREMENTS

Participants provided CME teaching effectiveness (CMETE) ratings using an instrument with known validity evidence. Overall CMETE scores (5-point scale: 1 = strongly disagree; 5 = strongly agree) were averaged for each presentation, and associations between scores and presentation characteristics were determined using the Kruskal-Wallis test. The threshold for statistical significance was set at P < 0.05.

RESULTS

A total of 277 out of 368 participants (75.3%) completed evaluations for the 32 presentations. CMETE scores (mean [standard deviation]) were significantly associated with the use of audience response (4.64 [0.16]) versus no audience response (4.49 [0.16]; P = 0.01), longer presentations (≥30 minutes: 4.67 [0.13] vs <30 minutes: 4.51 [0.18]; P = 0.02), and larger number of slides (≥50: 4.66 [0.17] vs <50: 4.55 [0.17]; P = 0.04). There were no significant associations between CMETE scores and use of clinical cases, defined goals, or summary slides.

CONCLUSIONS

To our knowledge, this is the first study regarding associations between validated teaching effectiveness scores and characteristics of effective CME presentations in HM. Our findings, which support previous research in other fields, indicate that CME presentations may be improved by increasing interactivity through the use of audience response systems and allowing longer presentations.

Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery

OBJECTIVE

The goal of this study was to assess outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis.

METHODS

A hospitalist comanagement program was implemented at a children's hospital. We conducted a retrospective case series study of patients during 2003-2008 to compare clinical and cost outcomes for 87 preimplementation patients, 40 patients during a partially implemented program, and 80 patients during a fully implemented program.

RESULTS

When compared with preimplementation patients, full implementation program patients did not demonstrate a statistically significant difference in median length of stay on the medical/surgical unit after transfer from the PICU (median: 6 vs 8 days; P = .07). Patients in the full implementation group received fewer days of parenteral nutrition (median: 0 vs 6 days; P = .0006) and had fewer planned and unplanned laboratory studies on the inpatient unit. There was no statistically significant change in returns to the operating room (P = .08 between preimplementation and full implementation), other complications, or 30-day readmissions. Median hospital costs increased from preimplementation ($59372) to partial implementation ($89302) and remained elevated during full implementation ($81 651) compared with preimplementation (P = .004). Mean physician costs followed a similar trajectory from preimplementation ($18425) to partial implementation ($24101) to full implementation ($22578; P = .0006 [versus preimplementation]).

CONCLUSIONS

A hospitalist comanagement program can significantly affect the care of medically complex children undergoing spinal fusion surgery. Initial program costs may increase.

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.

Job characteristics, satisfaction, and burnout across hospitalist practice models

BACKGROUND

Nearly two-thirds of hospitals in the United States are served by hospitalist physicians. How hospitalist work patterns and job satisfaction vary across various practice models is unknown.

METHODS

We administered the Hospitalist Worklife Survey to a randomized stratified sample of 3105 potential hospitalists and 662 hospitalist members of 3 multistate hospitalist companies. Details about respondents' hospitalist group characteristics, their work patterns, and satisfaction with 2 global and 11 domain measures were assessed. Factors influencing job satisfaction were also solicited. These factors, job characteristics, job satisfaction, and burnout were compared across predefined practice models.

RESULTS

The adjusted response rate was 25.6%. Among the respondents, 44% were employed by a hospital, 15% by a multispecialty physician group, 14% by a multistate hospitalist group, 14% by a university or medical school, 12% by a local hospitalist group, and 2% by other. Hospitalists of local groups reported more clinical shifts per month, and hospitalists of local and multistate groups reported more billable encounters per shift compared to other practice models. Academic hospitalists reported fewer night shifts, fewer billable encounters per shift, more nonclinical work hours, and lower earnings compared to other practice models. Differences in clinical and nonclinical responsibilities, and differences in factors most important to job satisfaction, were noted across the 5 models. Despite these differences, levels of global job satisfaction and burnout were similar across the practice models.

CONCLUSIONS

Work patterns, compensation, and hospitalists' priorities varied significantly across practice models. Overall job satisfaction and burnout were similar across models, despite these differences.

Worklife and satisfaction of hospitalists: toward flourishing careers

BACKGROUND

The number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.

OBJECTIVE

Determine current satisfaction levels among hospitalists.

DESIGN

Survey study.

METHODS

A national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.

RESULTS

There were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.

CONCLUSIONS

Hospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units

OBJECTIVES

The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units.

PARTICIPANTS

A multidisciplinary group of professionals with expertise in critical care education and clinical practice.

DATA SOURCES AND SYNTHESIS

Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report.

MAIN RESULTS

The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts.

CONCLUSIONS

Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.

Hospitalists at an academic medical center, part 2: guidelines and suggestions for the successful expansion of a voluntary pilot hospitalist program

Previously, the authors discussed the successful introduction of a pilot hospitalist program at an academic medical center. Here they examine best practices for the expansion of such a program. Many studies have shown hospitalists to be associated with improvements in hospital quality indicators such as decreased length of stay, but the conditions necessary for the expansion of a hospitalist program have received considerably less attention. The authors review guidelines and empirical evidence from the literature for the successful implementation of hospitalist programs generally and present specific recommendations for a previously described pilot hospitalist program at an academic medical center.

Evaluation of a hospitalist-run acute care for the elderly service

BACKGROUND

Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm.

OBJECTIVE

To evaluate a Hospitalist-run Acute Care for the Elderly (Hospitalist-ACE) service.

DESIGN

Quasi-randomized, controlled trial.

SETTING

Urban academic medical center.

PATIENTS

Medical inpatients age ≥70 years.

INTERVENTION

Hospitalist-ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum.

MEASURES

The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls.

RESULTS

One hundred twenty-two Hospitalist-ACE patients were compared to 95 usual care patients. Hospitalist-ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of "Do Not Attempt Resuscitation" orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist-ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30-day readmission rates (12% vs 10%, P = 0.50).

CONCLUSIONS

A Hospitalist-ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed.

Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore

PURPOSE

The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database.

METHODS

Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities.

RESULTS

Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities.

CONCLUSION

The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.

Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups

BACKGROUND

Few data describe the structure, activities, and goals of academic hospital medicine groups.

METHODS

We carried out a cross sectional email survey of academic hospitalist leaders. Our survey asked about group resources, services, recruitment and growth, as well as mentoring of faculty, future priorities, and general impressions of group stability.

RESULTS

A total of 57 of 142 (40%) potential hospitalist leaders responded to our email survey. Hospitalist groups were generally young (<5 years old). Hospitalist group leaders worried about adequate mentorship and burnout while placing a high priority on avoiding physician turnover. However, most groups also placed a high priority on expanding nonclinical activities (teaching, research, etc.). Leaders felt financially and philosophically unsupported, a sentiment which seemed to stem from being viewed primarily as a clinical rather than an academic service.

CONCLUSION

Academic hospital medicine groups have an acute need for mentoring and career development programs. These programs should target both individual hospitalists and their leaders while also helping to enhance scholarly work.

Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT)

BACKGROUND

Hospitalists care for an increasing percentage of hospitalized patients, yet evaluations of patient perceptions of hospitalists' communication skills are lacking.

OBJECTIVE

Assess hospitalist communication skills using the Communication Assessment Tool (CAT).

METHODS

A cross-sectional study of patients, age 18 or older, admitted to the hospital medicine service at an urban, academic medical center with 873 beds. Thirty-five hospitalists assigned to both direct care and teaching service were assessed.

MEASUREMENTS

Hospitalist communication was measured with the CAT. The 14-item survey, written at a fourth grade level, measures responses along a 5-point scale ("poor" to "excellent"). Scores are reported as a percentage of "excellent" responses.

RESULTS

We analyzed 700 patient surveys (20 for each of 35 hospitalists). The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5%, with an average of 59.1% excellent (SD=9.5). Highest ratings on individual CAT items were for treating the patient with respect, letting the patient talk without interruptions, and talking in terms the patient can understand. Lowest ratings were for involving the patient in decisions as much as he or she wanted, encouraging the patient to ask questions, and greeting the patient in a way that made him or her feel comfortable. Overall scale reliability was high (Cronbach's alpha = 0.97).

CONCLUSIONS

The CAT can be used to gauge patient perceptions of hospitalist communication skills. Many hospitalists may benefit from targeted training to improve communication skills, particularly in the areas of encouraging questions and involving patients in decision making.

The independent association of provider and information continuity on outcomes after hospital discharge: implications for hospitalists

BACKGROUND

Since hospitalist physicians do not frequently see patients in follow-up after discharge from the hospital, patient continuity of care will decrease. To determine how this influenced patient outcomes, we examined the independent association of several physician continuity and information continuity measures on death or urgent readmission after discharge from hospital.

DESIGN

Multicenter, prospective cohort study of patients discharged to the community after elective or emergency hospitalization. We measured three physician continuity scores (preadmission; hospital; and postdischarge) and two information continuity scores (discharge summary; postdischarge visit information) as time-dependent covariates. Continuity scores ranged from 0 (perfect discontinuity) to 1 (perfect continuity). The primary outcomes were time to all-cause death or urgent readmission.

RESULTS

A total of 3876 people were followed for a median of 175 days. Death rate was 2.6 events per 100 patient-years observation (pys) (95% confidence interval [CI], 2.0-3.4) and urgent readmission rate was 19.6 events per 100 pys (95% CI, 15.9-24.3). After adjusting for important covariates and other continuity scores, increased preadmission physician continuity was independently associated with a decreased risk of urgent readmission (adjusted hazard ratio 0.94 [95% CI, 0.91-0.98] for each absolute increase in continuity of 0.1). Other continuity measures-including hospital physician continuity-were not associated with either outcome.

CONCLUSIONS

After discharge from the hospital, increased continuity with physicians who routinely treated the patient prior to the admission was significantly and independently associated with a decreased risk of urgent readmission. These data suggest that continuity with the hospital physician after discharge did not independently influence the risk of patient death or urgent readmission.

The hospitalist as coordinator: an observational case study

PURPOSE

The hospitalist concept aims for integration and continuity of care in inpatient treatment. The purpose of this paper is to understand how the hospitalist function emerges and unfolds on wards. Therefore, the paper aims to focus on interaction patterns and the role of the hospitalist.

DESIGN/METHODOLOGY/APPROACH

Building on methodological approaches in health care team research, this process-oriented case study used participatory observations and semi-structured interviews. Over a year, 14 observational days were conducted, simultaneously accompanying hospitalists, nurses and surgeons. Observational data illustrate the findings.

FINDINGS

The hospitalist function was perceived to have a positive impact. He/she serves as an informal leader by taking up five interrelated, mostly coordinative roles, which help to cope with different organisational gaps. The interaction patterns are bilateral, ad hoc, reactive, repetitive and dependent on chance and people. Roles, tasks and responsibilities are continuously negotiated.

RESEARCH LIMITATIONS/IMPLICATIONS

Hospitalist research should make use of the debate in health care team research about overlapping roles, tasks and responsibilities. Additionally, one could look at the origins behind the evolvement of interaction patterns and the hospitalist's roles.

PRACTICAL IMPLICATIONS

The sole creation of the hospitalist function is not sufficient to tap its full potential. Organisational issues concerning the interaction processes need to be addressed. In so doing, the professions' orientations must be taken into account.

ORIGINALITY/VALUE

This paper addresses theoretical and methodological gaps in hospitalist research. Using a process-oriented qualitative design, the findings question the prominent stimulus-response assumption. The focus on the interplay of functions and the hospitalists' roles lead to a more comprehensive picture of the patient-related interaction processes.

Procedures performed by hospitalist and non-hospitalist general internists

BACKGROUND

In caring exclusively for inpatients, hospitalists are expected to perform hospital procedures. The type and frequency of procedures they perform are not well characterized.

OBJECTIVES

To determine which procedures hospitalists perform; to compare procedures performed by hospitalists and non-hospitalists; and to describe factors associated with hospitalists performing inpatient procedures.

DESIGN

Cross-sectional survey.

PARTICIPANTS

National sample of general internist members of the American College of Physicians.

METHODS

We characterized respondents to a national survey of general internists as hospitalists and non-hospitalists based on time-activity criteria. We compared hospitalists and non-hospitalists in relation to how many SHM core procedures they performed. Analyses explored whether hospitalists' demographic characteristics, practice setting, and income structure influenced the performance of procedures.

RESULTS

Of 1,059 respondents, 175 were classified as "hospitalists". Eleven percent of hospitalists performed all 9 core procedures compared with 3% of non-hospitalists. Hospitalists also reported higher procedural volumes in the previous year for 7 of the 9 procedures, including lumbar puncture (median of 5 by hospitalists vs. 2 for non-hospitalists), abdominal paracentesis (5 vs. 2), thoracenteses (5 vs. 2) and central line placement (5.5 vs. 3). Performing a greater variety of core procedures was associated with total time in patient care, but not time in hospital care, year of medical school graduation, practice location, or income structure. Multivariate analysis found no independent association between demographic factors and performing all 9 core procedures.

CONCLUSIONS

Hospitalists perform inpatient procedures more often and at higher volumes than non-hospitalists. Yet many do not perform procedures that are designated as hospitalist "core competencies."

Hospitalists and intensivists: partners in caring for the critically ill--the time has come

A report by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS), published in 2000, predicted that beginning in 2007 a gap between the demand and availability of intensivists in the United States would become apparent and steadily increase to 22% by 2020 and to 35% by 2030. Subsequent reports have reiterated those projections including a report to congress in 2006 by the U.S. Department of Health and Human Services/Health Resources and Services Administration. This "gap" has been called a health system "crisis" by multiple authors. Two important documents have published specific recommendations for how to resolve this crisis: the Framing Options for Critical Care in the United States (FOCCUS) Task Force Report in 2004 and the Prioritizing the Organization and Management of Intensive Care Services in the Unites States (PrOMIS) Conference Report in 2007. Since the initial COMPACCS report and since these 2 additional reports were published, a new opportunity to take a major step in resolving this crisis has emerged: the growing number of hospitalists providing critical care services at secondary and tertiary care facilities. According to the 2005/2006 Society of Hospital Medicine (SHM) National Survey, that number has increased to 75%. Since the number of intensivists is unlikely to change significantly over the next 25 years, the question is no longer "if" hospitalists should be in the intensive care unit (ICU); rather the question is how to assure quality and improved clinical outcomes through enhanced collaboration between hospital medicine and critical care medicine.

California hospital leaders' views of hospitalists: meeting needs of the present and future

BACKGROUND

Hospital medicine has grown rapidly, but hospital leaders' perceptions of current and future drivers of hospitalist growth are unknown.

OBJECTIVE

: To determine hospital executives' perceptions of factors leading to hospitalist implementation and their vision for hospitalists' work roles.

SETTING

Nonfederal, acute care hospitals in California.

PARTICIPANTS

California hospital leaders (eg, chief executive officers).

INTERVENTION

Cross-sectional survey from 2006 to 2007.

MEASUREMENTS

We asked California hospital leaders whether their hospitals had a hospitalist service and the prospects for growth. In addition, we examined factors responsible for implementation, scope of hospitalists' practices, and need for additional certification as perceived by hospital leaders.

RESULTS

We received surveys from 179 of 334 hospitals (response rate of 54%). Of the 64% of respondents that reported the use of hospitalists, none intended to decrease the size of their hospitalist group, and 57% expected growth over 2 years. The most common reasons for implementing a hospitalist program were to care for uncovered patients (68%) and improve cost/length of stay (63%). Respondents also indicated that demand from other physicians was an important factor. Leaders reported that hospitalists provide a wide range of services, with a majority involved in quality improvement projects (72%) and medical comanagement of surgical patients (66%). Most leaders favor additional certification for hospitalists.

CONCLUSIONS

There is widespread adoption of hospitalists in California hospitals, with an expectation of continued growth. The drivers of the field's growth are evolving and dynamic. In particular, attentiveness to quality performance and demand from other physicians are increasingly important reasons for implementation.

Effect of hospitalist attending physicians on trainee educational experiences: a systematic review

BACKGROUND

Trainees receive much of their inpatient education from hospitalists.

PURPOSE

To characterize the effects of hospitalists on trainee education.

DATA SOURCES

MEDLINE, Database of Reviews of Effectiveness (DARE), National Health Service (NHS) Economic Evaluation Database (EED), Health Technology Assessment (HTA), and the Cochrane Collaboration Database (last searched October 2008) databases using the term "hospitalist", and meeting abstracts from the Society of Hospital Medicine (SHM) (2002-2007), Society of General Internal Medicine (SGIM) (2001-2007), and Pediatric Academic Societies (PAS) (2000-2007).

STUDY SELECTION

Original English language research studies meeting all of the following: involvement of hospitalists; comparison to nonhospitalist attendings; evaluation of trainee knowledge, skills, or attitudes. 711 articles were reviewed, 32 retrieved, and 6 included; 7,062 meeting abstracts were reviewed, 9 retrieved, and 2 included.

DATA EXTRACTION

Two authors reviewed articles to determine study eligibility. Three authors independently reviewed included articles to abstract data elements and classify study quality.

DATA SYNTHESIS

Seven studies were quasirandomized one was a noncontemporaneous comparison. All citations only measured trainee attitudes. In all studies comparing hospitalists to nonhospitalists, trainees were more satisfied with hospitalists overall, and with other aspects of their teaching, but ratings were high for both groups. One of 2 studies that distinguished nonhospitalist general internists from specialists showed that trainees preferred hospitalists, but the other did not demonstrate a hospitalist advantage over general internists.

CONCLUSIONS

Trainees are more satisfied with inpatient education from hospitalists. Whether the increased satisfaction translates to improved learning is unclear.

The impact of adding 1 month of intensive care unit training in a categorical internal medicine residency program

OBJECTIVE

To determine the impact of adding a month of critical care training in the postgraduate year (PGY)-2 on the critical care skills of PGY-3 residents.

DESIGN

Prospective, nonrandomized.

SETTING

The internal medicine (IM) residency program of a tertiary care medical center.

STUDY SUBJECTS

The study subjects included the 2005/2006 and 2006/2007 academic year IM residents.

INTERVENTIONS

The 2005/2006 IM residents (control group, n = 48) had 1 month of critical care training (internship year) before their 1-month PGY-3 rotations. The 2006/2007 residents (intervention group, n = 47) had an additional 1-month rotation in a multispecialty intensive care unit (ICU) during their second year.

MEASUREMENTS AND MAIN RESULTS

At the beginning of their last ICU month rotation, the intervention group's self-assessment (1-5 Likert scale) of their skills in internal jugular venous catheterization (3.4 vs. 2.4, p < 0.001) and management of severe sepsis (4.0 vs. 2.4, p < 0.001) and acute lung injury (3.3 vs. 2.6, p < 0.001) was higher than that of the control group. However, the observed success rates of endotracheal intubation (55.4% vs. 54.9%, p = 0.953) and central venous catheterization (78.1% vs. 80.8%, p = 0.488) were similar between the two groups. No difference was noted in the complication rates for endotracheal intubation or central venous catheterization between the control and intervention groups. End of ICU rotation examination results, attending evaluations, and the observed application of evidence-based practice in the management of severe sepsis were similar between the two groups.

CONCLUSIONS

Increasing IM residents' experience in the ICU resulted in modest, transient improvement of their perceived clinical skills in critical care procedures and management of severe sepsis and acute lung injury. However, no statistically significant and sustained improvement was noted in the observed cognitive or clinical skills.

Physician staffing models and patient safety in the ICU

Despite the manpower shortage to care for the critically ill, the number of ICU beds has been rising for the last 2 decades. The ICU intensivist physician staffing model is still in flux in this country. Despite a challenge by a recent single publication, numerous studies have shown that high-intensity intensivist staffing improves patient outcome in the ICU. However, 73% of the ICUs in this country provide low-intensity or no intensive care coverage. Although it may not be possible to implement 24 h/d intensivist coverage of all ICUs at this time, we believe it is the best model for achieving good patient outcome. The mere presence of intensivists in the ICU is unlikely to improve patient outcome unless it is associated with the creation of an organizational environment ideal for the implementation of evidence-based practice. In this commentary, we will discuss the available evidence behind the current models and express our opinions about current and future ICU intensivist staffing.

Growth in the care of older patients by hospitalists in the United States

BACKGROUND

National and population-based information on the increase in patient care by hospitalists in the United States is lacking.

METHODS

Using a 5% sample of Medicare beneficiaries in 1995, 1997, 1999, and the period from 2001 through 2006, we identified 120,226 physicians in general internal medicine who were providing care to older patients in 5800 U.S. hospitals. We defined hospitalists as general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients. We then calculated the percentage of all inpatient Medicare services provided by hospitalists and identified patient and hospital characteristics associated with the receipt of hospitalist services.

RESULTS

The percentage of physicians in general internal medicine who were identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006, and the percentage of all claims for inpatient evaluation-and-management services by general internists that were attributed to hospitalists increased from 9.1% to 37.1% during this same period. Accompanying the increase in care by hospitalists was an increase in the percentage of all hospitalized Medicare patients who were treated by general internists (both hospitalists and traditional, non-hospital-based general internists), from 46.4% in 1995 to 61.0% in 2006. In a multilevel, multivariable analysis controlling for patient and hospital characteristics, the odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70% in some hospital-referral regions.

CONCLUSIONS

These analyses of data from Medicare claims showed a substantial increase in the care of hospitalized patients by hospitalist physicians from 1995 to 2006.

Achieving hospital medicine's promise through internal medicine residency redesign

The promise of the hospital medicine movement is that the hospitalist model of care will provide better outcomes than the system it replaced. This means improving the quality and processes of care, reducing inefficiencies and lowering costs. Despite some documented improvements in these areas hospitalists have yet to achieve their pinnacle. These shortfalls likely result from training providers in residencies that have yet to evolve to address the specific needs of hospitalists. While most internal medicine residency training programs stress inpatient care they underemphasize key components of a successful hospitalist career. This paper overviews the state of the hospitalist movement, the current educational training deficiencies and the methods to deliver hospitalist-focused training.

Where should hospitalists sit within the academic medical center?

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine's current trajectory and provide recommendations for hospital medicine's place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions.

Pediatric intensivist extenders in the pediatric ICU

This article explores the use of physician extenders in the pediatric ICU setting. The Libby Zion case is highlighted because of its impact on the use of manpower in the hospital setting. The history of physician extenders, including the hospitalist, physician assistant (PA), and nurse practitioner (NP), is discussed. Findings indicate a positive impact within the pediatric intensive care setting with the use of NPs and PAs. The American Academy of Pediatrics has supported the use of physician extenders in the care of hospitalized children.

Critical care workforce

OBJECTIVE

The recent Health Resources and Services Administration report on critical care manpower details the impending crisis in the critical care workforce in the United States.

DESIGN

A review of the Health Resources and Services Administration statistics indicate the present structure for training critical care physicians through combined pulmonary/critical care fellowships is, and will remain, woefully inadequate to meet demand.

INTERVENTION

Training for intensive care unit physicians will require new paradigms for training, including consideration of free-standing critical care residencies and multidisciplinary critical care fellowships.

CONCLUSION

Unless the training structure changes, the worsening shortage of intensivists will precipitate a crisis, resulting in the disintegration of critical care delivery in the United States.

Neurohospitalists: an emerging model for inpatient neurological care

Over the past decade, the hospitalist model has become a dominant system for the delivery of general adult and pediatric inpatient care. Similar forces, including national mandates to improve safety and quality and intense pressure to safely reduce length of hospital stays, that led to the remarkable growth of hospitalist medicine are now exerting pressure on neurologists. A neurohospitalist model, in which inpatient neurology specialists deliver high-quality and efficient care to neurology patients, is emerging to meet these challenges. Benefits of this system may include more frequent, timely neurology consultations in the hospital and emergency department, as well as improved quality of inpatient neurological education for residents and medical students. Challenges will involve defining the relationship of neurohospitalists with primary stroke centers, the economic feasibility of such neurohospitalist systems, and how to train members of this new field. A neurohospitalist model of care is an emerging idea in neurology that would overcome many regulatory, educational, and economic challenges facing neurologists; further research is needed to gauge the effects of this innovative approach.

Critical care medicine for the hospitalist

The aim of this article is to review some of the important topics in critical care medicine, including the latest management recommendations for sepsis, the use of noninvasive ventilation in respiratory failure, and practice guidelines for transfusion in critically ill patients.

Pediatric hospitalist comanagement of surgical patients: challenges and opportunities

Hospitalists are increasingly providing comanagement of surgical patients. Limited data published regarding hospitalist comanagement of adult surgical patients have suggested that these partnerships may help improve outcomes and limit resource usage. Pediatric surgical comanagement programs at community hospitals will face different clinical challenges than those at tertiary referral pediatric centers. Pediatric hospitalists providing surgical comanagement must also address specific administrative issues including program structure, communication, staffing, and finances.

Outcomes of care by hospitalists, general internists, and family physicians

BACKGROUND

The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians.

METHODS

We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians.

RESULTS

As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar.

CONCLUSIONS

For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.

Comparison of hospital costs and length of stay for community internists, hospitalists, and academicians

BACKGROUND

The model of inpatient medical management has evolved toward Hospitalists because of greater cost efficiency compared to traditional practice. The optimal model of inpatient care is not known.

OBJECTIVE

To compare three models of inpatient Internal Medicine (traditional private practice Internists, private Hospitalist Internists, and Academic Internists with resident teams) for cost efficiency and quality at a community teaching hospital.

DESIGN

Single-institution retrospective cohort study.

MEASUREMENTS AND MAIN RESULTS

Measurements were hospital cost, length of stay (LOS), mortality, and 30-day readmission rate adjusted for severity, demographics, and case mix. Academic Internist teams had 30% lower cost and 40% lower LOS compared to traditional private Internists and 24% lower cost and 30% lower LOS compared to private Hospitalists. Hospital mortality was equivalent for all groups. Academic teams had 2.3-2.6% more 30-day readmissions than the other groups.

CONCLUSIONS

Academic teams compare favorably to private Hospitalists and traditional Internists for hospital cost efficiency and quality.

Expanding the roles of hospitalist physicians to include public health

Several years after the inception of the hospitalist movement, hospitalist roles have evolved in breadth and sophistication. Although public health is not formally recognized or previously described as an arena for hospitalists, hospitalists are often engaged in public health practice. This article attempts to alert hospitalists to the potential to make contributions to the field of public health and defines the public health skills that can positively affect the lives of their patients and the communities they serve. In a public health role, hospitalists may improve the quality of inpatient care. This article reviews how public health and hospital-based practices have already intersected and proposes further development within this discipline. In our ever-changing health care system, hospitalists play key roles in the central public health domains of assessment, assurance, and policy development. Insightful hospitalists will recognize and embrace these responsibilities in caring for patients and society.

Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements

BACKGROUND

The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996.

METHODS

We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement.

RESULTS

Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%).

CONCLUSIONS

Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.

Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery

OBJECTIVE

To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery.

PATIENTS AND METHODS

We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined "hospitalist" as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants.

RESULTS

Both TTC and TTS were significantly lower for hospitalist patients (P < .001 and P = .004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated dollar 1777 less, and median LOS was 1 day less than in the nonhospitalist group.

CONCLUSION

Hospitalist Involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.

Hospitalists

The hospitalist "specialty" is sweeping the inpatient setting with numbers of physicians choosing this specialty expected to exceed 20,000 by 2010. Yet, little is known about the involvement of nursing in the design, implementation, and evaluation of a hospitalist initiative. The author suggests the chief nursing officer's pivotal role in proactively encouraging the design and implementation of a hospitalist-nurse manager patient-centered care delivery model. The chief nursing officer can create an environment to foster research designed to identify outcomes from this partnership of hospitalist and clinical (nurse) manager.

A comparison of two hospitalist models with traditional care in a community teaching hospital

PURPOSE

Many studies have documented significant length of stay reduction and cost savings when hospitalist care is compared with traditional care. However, less is known about the concurrent performance of more than one hospitalist model in a single site.

SUBJECTS AND METHODS

This retrospective cohort study of 10595 patients was conducted between July 2001 and June 2002 in a tertiary care community-based teaching hospital. Risk-adjusted length of stay, variable costs, 30-day readmission rates, and in-hospital and 30-day mortality were measured for patients treated by Community Physicians, Private Hospitalists and Academic Hospitalists.

RESULTS

There was a 20% reduction in length of stay on the Academic Hospitalist service (p <.0001) and 8% on the Private Hospitalist service (P = .049) compared with Community Physicians. Similarly, total costs were 10% less on the Academic (P <.0001) and 6% less on the Private Hospitalist (P = .02) services compared with Community Physicians. The length of stay of Academic Hospitalists was 13% shorter than that of Private Hospitalists (P = .002); differences in costs between hospitalist groups were not statistically significant. Differences in in-hospital and 30-day mortality and 30-day readmission rates among the 3 physician groups were also not statistically significant.

CONCLUSIONS

The impact on patient outcomes and resource utilization may vary with the hospitalist model used. Future studies should examine the specific organizational characteristics of hospitalists that contribute to improved patient care and resource utilization.

Effect of closed unit policy and appointing an intensivist in a developing country

OBJECTIVE

We hypothesized that a dual strategy--instituting a closed intensive care unit (ICU) policy and simultaneously appointing an intensivist--would improve patient outcome in a university hospital of a developing country and that the benefit would increase over time.

DESIGN

Data were prospectively collected over 5 months before the policy change (open policy) and over an initial 6 mos (early closed policy) and subsequent 12 mos (late closed policy) after the policy change.

SETTING

The study was conducted at a medical ICU of a university hospital in Turkey.

PATIENTS

Two hundred patients were recruited during open policy, 149 during early closed policy, and 210 during late closed policy.

MEASUREMENTS AND RESULTS

Instituting a closed policy and simultaneously appointing a critical care specialist was associated with the admission of sicker patients and more frequent use of invasive procedures. Compared with open policy, patients were approximately 4.5 times more likely to survive their hospital stay during early closed policy (p < .001) and approximately five times more likely during late closed policy (p < .0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%) than during open period (91%; p < .01). In multivariate analysis, open policy, mechanical ventilation, central venous catheterization, sepsis, and higher Acute Physiology and Chronic Health Evaluation II score each independently predicted mortality. The change in policy resulted in the admission of progressively sicker patients over time and increased the use of mechanical ventilation and central venous catheters.

CONCLUSION

A dual strategy of closed policy and simultaneously appointing an intensivist fostered admission of sicker patients and improved the survival of patients requiring admission to an ICU of a developing country.

Doing the Same and Earning Less: Male and Female Physicians in a New Medical Specialty

This study presents findings from a national survey of physicians working in the emerging career of hospital medicine. It finds that female hospitalists earn significantly less annually than male hospitalists, despite similar work schedules and commitments; that these similarities in work and differences in pay remain even for male and female hospitalists who are married and have children; and that female hospitalists maintain positive feelings toward their work careers despite assuming multiple work and nonwork roles simultaneously. The results present a unique picture of female physicians career experiences in toto. They have implications for how health care organizations and managers should think about the contemporary female physician (e.g., her career development needs and workplace challenges); for female physicians need to gain greater equity vis-à-vis men within the profession; and for the kinds of questions researchers should raise around physician gender in their work.

End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms

PURPOSE

To assess the effects of hospitalist care on communication, care patterns, and outcomes of dying patients.

METHODS

We examined the charts of 148 patients who had died at a community-based, urban teaching hospital, comparing the end-of-life care provided by community physicians and hospitalists.

RESULTS

Patients of hospitalists and community-based physicians were similar in age, race, severity of acute illness, and difficulties with activities of daily living. After admission, hospitalists had discussions with patients or their families regarding care more often than did community physicians (91% [67/74] vs. 73% [54/74], P = 0.006) and were more likely to document these discussions themselves. Among patients who were "full code" at admission, there was a trend towards patients of hospitalists receiving comfort care more frequently at the time of death (50% [25/48] vs. 37% [15/40], P = 0.14). Although there were no differences in the use of medications such as long-acting opioids, no symptoms in the 48 hours prior to death were more likely to be noted for patients of hospitalists (47% [n = 35] vs. 31% [n = 23]), P = 0.03). After adjustment for confounding factors in multivariable models, only findings regarding documentation of discussions and symptoms remained statistically significant.

CONCLUSION

Hospitalists at a community-based teaching hospital documented substantial efforts to communicate with dying patients and their families, which may have resulted in improved end-of-life care.

The hospitalist movement: wise or wishful thinking?

One-third of all health care expenditures--nearly 5% of the gross domestic product--relates to hospital care. Can hospitalists provide the financial solution?

CEO's perceptions of hospitalists: diffusion of the strategy

Many hospitals have initiated a strategy to reduce costs and improve quality of care by using physicians as "hospitalists." A hospitalist specializes in inpatient care. This article reports the findings of survey research examining CEO perceptions of the hospitalist model, with particular interest in diffusion of the strategy in rural and low managed care hospital markets. Findings indicate there is less diffusion of the hospitalist model to rural areas because of lack of information about the cost effectiveness of the program and medical staff resistance. Recommendations to increase adoption of the hospitalist strategy include educating about the benefits of the strategy and paying attention to areas of concern by the medical staff.

Hospitalists as teachers

OBJECTIVE

To compare evaluations of teaching effectiveness among hospitalist, general medicine, and subspecialist attendings on general medicine wards.

DESIGN

Cross-sectional.

SETTING

A large, inner-city, public teaching hospital.

PARTICIPANTS

A total of 423 medical students and house staff evaluating 63 attending physicians.

MEASUREMENTS AND MAIN RESULTS

We measured teaching effectiveness with the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey, and reviewed additional written comments. The response rate was 81%. On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of subspecialists (126.3 [95% CI, 120.4 to 132.1]), P =.03. General medicine attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than subspecialists, P =.01. Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than did more distant graduates (129.1 [95% CI, 125.1 to 133.1]), P =.006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P =.05. Qualitative analysis of written remarks revealed that trainees valued faculty who were enthusiastic teachers, practiced evidence-based medicine, were involved in patient care, and developed a good rapport with patients and other team members. These characteristics were most often noted for hospitalist and general medicine attendings.

CONCLUSIONS

On general medicine wards, medical students and residents considered hospitalists and general medicine attendings to be more effective teachers than subspecialists. This effect may be related to the preferred faculty members exhibiting specific characteristics and behaviors highly valued by trainees, such as enthusiasm for teaching and use of evidence-based medicine.

Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations

PURPOSE

To evaluate the impact of academic hospitalists on third-year medical students during inpatient medicine rotations.

METHOD

The authors conducted a retrospective quantitative assessment of medical student evaluations of hospitalist and nonhospitalist Department of Medicine faculty at Oregon Health & Science University, for the 1998-00 academic years. Using a nine-point Likert-type scale, students evaluated the faculty on the following characteristics: communication of rotation goals, establishing a favorable learning climate, use of educational time, teaching style, evaluation and feedback, contributions to the student's growth and development, and overall effectiveness as a clinical teacher.

RESULTS

A total of 138 students rotated on the university wards during the study period; 100 with hospitalists, and 38 with nonhospitalists. Of these students, 99 (71.7%) returned evaluations. The hospitalists received higher numeric evaluations for all individual attending characteristics. Significance was achieved comparing communication of goals (p =.011), effectiveness as a clinical teacher (p =.016), and for the combined analysis of all parameters (p <.001). Despite lack of achieving statistical significance, there was a trend toward hospitalists being more likely to contribute to the medical student's perception of growth and development during the period evaluated (p =.065).

CONCLUSIONS

In addition to performing the responsibilities required of full-time hospital-based physicians, hospitalists were able to provide at least as positive an educational experience as did highly rated nonhospitalist teaching faculty and in some areas performed better. A hospitalist model can be an effective method of delivering inpatient education to medical students.