Journal of General Internal Medicine

, Volume 33, Issue 4, pp 449–454 | Cite as

Service and Education: The Association Between Workload, Patient Complexity, and Teaching on Internal Medicine Inpatient Services

  • Temple A. Ratcliffe
  • Meghan A. Crabtree
  • Raymond F. Palmer
  • Jacqueline A. Pugh
  • Holly J. Lanham
  • Luci K. Leykum
Original Research

Abstract

Background

Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds.

Objective

To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables.

Design

Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks.

Participants

Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students.

Main Measures

The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission.

Key Results

We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549] = 6.90, p < 0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient’s admission; F[8,548] = 14.18, p < 0.001).

Conclusions

Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.

KEY WORDS

medical education medical education–graduate medical education–undergraduate hospital medicine 

Notes

Acknowledgements

We would like to thank the members of the teams involved in this study.

Contributors

None.

Prior Presentations

None.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. J Hosp Med. 2009;4(5):304–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Stickrath C, Noble M, Prochazka A, Anderson M, Griffiths M, Manheim J, Sillau S, Aagaard E. Attending rounds in the current era: what is and is not happening. JAMA Intern Med. 2013;173(12):1084–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Shoeb M, Khanna R, Fang M, Sharpe B, Finn K, Ranji S, Monash B. Internal medicine rounding practices and the Accreditation Council for Graduate Medical Education core competencies. J Hosp Med. 2014;9(4):239–43.CrossRefPubMedGoogle Scholar
  4. 4.
    Accreditation Council for Graduate Medical Education. Common Program Requirements. http://www.acgme.org/Portals/0/PDFs/Common_Program_Requirements_07012011[2].pdf. Accessed December 19, 2017.
  5. 5.
    O’Conner AB, Lang VL, Bordley DR. Restructuring an inpatient resident service to improve outcomes for residents, students and patients. Acad Med 2011;86(12):1500–7.CrossRefGoogle Scholar
  6. 6.
    Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786–93.CrossRefPubMedGoogle Scholar
  7. 7.
    Kripalani S, Pope AC, Rask K, Hunt K, Dressler DD, Branch WT, Zhang R, Williams MV. Hospitalists as teachers. J Gen Intern Med. 2004;19(1):8–15.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;19(4):392–3.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Tierney MJ, Pageler NM, Kahana M, Pantaleoni JL, Longhurst CA. Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions. Acad Med. 2013;88(6):748–52.CrossRefPubMedGoogle Scholar
  10. 10.
    Reilly JB, Bennett N, Fosnocht K, Williams K, Kangovi S, Jackson R, Ende J. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450–3.CrossRefPubMedGoogle Scholar
  11. 11.
    McGee S. A piece of my mind. Bedside teaching rounds reconsidered. JAMA. 2014;311(19):1971–2.CrossRefPubMedGoogle Scholar
  12. 12.
    Gonzalo JD, Chuang CH, Huang G, Smith C. The return of bedside rounds: an educational intervention. J Gen Intern Med. 2010;25(8):792–8.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Leykum LK, Chesser H, Lanham HJ, Carla P, Palmer R, Ratcliffe T, Reisinger H, Agar M, Pugh J. The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients' Outcomes. J Gen Intern Med. 2015;30(12):1821–7.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Leykum LK, Lanham HJ, Provost SM, McDaniel RR, Pugh J. Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol. Implement Sci. 2014;9:171.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    McAllister C, Leykum LK, Lanham H, Reisinger HS, Kohn JL, Palmer R, Pezzia C, Agar M, Parchman M, Pugh J, McDaniel RR Jr. Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes. J Hosp Med. 2014;9(12):764–71.CrossRefPubMedGoogle Scholar
  16. 16.
    American Board of Internal Medicine. Internal Medicine Certification Examination Blueprint. https://www.abim.org/~/media/ABIM%20Public/Files/pdf/exam-blueprints/certification/internal-medicine.pdf Accessed December 19, 2017.
  17. 17.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Priest JR, Bereknyei S, Hooper K, Braddock CH 3rd. Relationships of the location and content of rounds to specialty, institution, patient-census and team size. PLoS One. 2010;5(6):e11246.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Goldszmidt M, Faden L, Dornan T, van Merriënboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Acad Med. 2015;90(11):1541–6.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine (outside the USA) 2018

Authors and Affiliations

  • Temple A. Ratcliffe
    • 1
    • 2
  • Meghan A. Crabtree
    • 3
  • Raymond F. Palmer
    • 1
  • Jacqueline A. Pugh
    • 1
    • 2
  • Holly J. Lanham
    • 1
    • 2
    • 4
  • Luci K. Leykum
    • 1
    • 2
    • 4
  1. 1.University of Texas Health Science Center at San AntonioSan AntonioUSA
  2. 2.South Texas Veterans Health Care SystemSan AntonioUSA
  3. 3.University of Texas at San AntonioSan AntonioUSA
  4. 4.University of Texas at AustinAustinUSA

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