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



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.


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


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.


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).


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


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



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



Prior Presentations



The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07–022). Investigator salary support is provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Compliance with Ethical Standards

Conflict of Interest

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


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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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