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Effect of a Pediatric Hospitalist System on Housestaff Education and Experience
Christopher P. Landrigan, MD, MPH;
Sharon Muret-Wagstaff, PhD;
Vincent W. Chiang, MD;
Daniel J. Nigrin, MD, MS;
Donald A. Goldmann, MD;
Jonathan A. Finkelstein, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:877-883.
ABSTRACT
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Objective To determine the effect of a pediatric hospitalist system on housestaff
education and experience.
Setting Free-standing academic children's hospital. Hospitalists were introduced
in June 24, 1998, to supervise teaching and care on the general pediatric
wards.
Methods On 2 surveys, housestaff rated their skills, knowledge, and experiences
on the wards (experiences survey), and the quality of teaching and supervision
by attending physicians (attending survey). Responses before and after the
introduction of the hospitalist system were compared using Wilcoxon nonparametric
tests.
Results Seventy-six (70%) of the 109 interns and 54 (62%) of the 87 senior residents
responded to the experiences survey. Following introduction of the hospitalist
system, the interns' mean overall rating of the general pediatrics wards rose
from 4.1 to 4.7 on a 5-point Likert scale (P = .01).
Their ratings of comparison rotations did not change significantly. Interns'
satisfaction with the educational experience (3.2 to 3.5 of a 4-point Likert
scale, P<.05), supervision, and quality of life
on the pediatrics wards also improved significantly, as did their self-assessments
of skills and knowledge related to general pediatrics training. Senior residents'
ratings were generally unchanged. Three hundred seventy-one (63%) of the 593
attending physicians' surveys were completed. Compared with nonhospitalist
attendings, hospitalists were rated more effective role models (4.7 vs 4.5
points, P<.05) and teachers (4.7 vs 4.4 points, P<.01). They were rated more knowledgeable (4.8 vs 4.5
of 5, P<.001) and accessible (4.7 vs 4.5 points, P<.05), involved housestaff more in the learning process
(4.7 vs 4.4 points, P<.05), and gave better feedback
(4.5 vs 4.2 points, P<.01). Hospitalists' bedside
teaching, however, was rated lower (3.7 vs 4.2 points, P<.001).
Conclusions Overall, hospitalists were rated significantly higher as educators than
were traditional attending physicians. Introduction of a hospitalist system
was associated with improved intern experience and quality of life on general
pediatrics wards, and with improved self-reported skills and knowledge in
general pediatrics.
INTRODUCTION
HOSPITALISTS, PHYSICIANS spending at least 25% of their time providing
care for hospitalized patients referred by their primary care physicians,
are increasingly prevalent in the United States.1
In a national survey of pediatric department chairs, we found that 50% of
academic pediatric centers have begun to use hospitalists, and more than three
quarters are planning to use them in the future.2
Most studies have found that pediatric and adult hospitalist systems decrease
inpatient costs and length of stay without adversely affecting mortality or
readmission rates.3-10
The effect of hospitalist systems on trainees' experience is less well documented.
Proponents of hospitalist models suggest that hospitalists' inpatient
expertise will lead to improvements in inpatient teaching and supervision.11 Several preliminary studies support this assertion,
demonstrating improved housestaff satisfaction or ratings of overall experience
on hospitalist services,3, 6, 12
but others have found no such improvement.13-14
Very few studies have attempted to critically compare the training process
in hospitalist systems with traditional systems, or to differentiate the effects
of hospitalist systems on senior residents and interns. Uncontrolled surveys
have found hospitalists' teaching rated highly in a variety of specific domains,15-16 but comparative data are lacking.
The most detailed, controlled evaluation was published by Wachter et al3 at the University of California, San Francisco; they
compared residents' learning on hospitalist-staffed services with that on
traditionally staffed services.3 Residents
reported learning more about cost-effectiveness on the hospitalist service;
no differences were found in resident-reported learning of pathophysiology,
practice guidelines, evidence-based medicine, or preparation for practice.
While these studies have provided insights into education in hospitalist
systems, they have not thoroughly explored the influence of hospitalists on
overall resident education.17 Very few data
on the strengths and weaknesses of hospitalists as educators have been provided.
Studies of housestaff education and experience in pediatric hospitalist systems
have been particularly limited.
We hypothesized that the introduction of hospitalists in a large free-standing
pediatric teaching hospital would improve (1) housestaff ratings of their
general pediatrics rotations and attending physicians, (2) housestaff skills
and knowledge in inpatient general pediatrics, and (3) housestaff knowledge
and use of evidence-based medicine. To test these hypotheses, we compared
housestaff ratings of their own experiences, skills, and knowledge, as well
as the quality of education provided by attending physicians, before and after
introduction of a hospitalist system.
PARTICIPANTS AND METHODS
SETTING
On June 24, 1998, the study hospital reorganized its medical services
in an effort to improve the quality of patient care and to improve resident
and medical student education. Changes occurred throughout the medical center,
including the general pediatrics wards. Eight hospitalists were hired as salaried
employes to supervise the senior resident (postgraduate year 3 [PGY3]), 4
interns (postgraduate year 1 [PGY1]), and 3 to 4 medical students on each
general pediatrics ward team. This hospitalist system replaced a traditional
system in which approximately 75 general pediatricians and subspecialists
volunteered 2 weeks to 1 month each year to teach and care for hospitalized
patients on 3 general pediatrics teams. Most of these attending physicians
did not go to residents' daily work rounds, and most were available in-house
for only part of the day, although they were available by page.
Six of the hospitalists were drawn from the Division of General Pediatrics
and the Division of Emergency Medicine at the study hospital; the remaining
2 came from subspecialties within the Department of Medicine. Each served
as a hospitalist for 3 to 4 months per year. While on service, hospitalists
were the attendings-of-record for most general pediatric inpatients, and were
present at work and teaching rounds every day. They were available for clinical
care, supervision, and teaching throughout the day. At night, they were available
by telephone. Responsibilities for didactic teaching of housestaff and students
were shared with a "teaching attending," a subspecialist or community pediatrician
volunteering to help with teaching for 2 weeks to 1 month per year.
SURVEY INSTRUMENTS
Two anonymous surveys were used to address housestaff experiences in
inpatient general pediatrics. The first was an annual survey in which housestaff
rated their rotations and their skills and knowledge (experiences survey).
The second was a survey completed at the end of each general pediatrics ward
rotation in which housestaff rated the teaching and supervisory skills of
attending physicians (attending survey).
Experiences Survey
At the end of each academic year, the study hospital administers a detailed
survey asking its pediatric housestaff to rate their skills, knowledge, and
educational opportunities; feedback, advising, and support provided; conferences;
rotations; quality of life; and overall impressions of the program.
Prior to the 1997-1998 survey administration, we added new items to
specifically assess housestaff experience of the quality of life, support,
supervision, and autonomy on the general pediatrics wards. The residency program
directors and representatives of the housestaff participated in the process
of generating the new survey questions. The redesigned survey was administered
both before the introduction of hospitalists in April 1998 and afterward in
April 1999 and April 2000. From the new items specific to the general pediatrics
teams, and from items on the survey assessing residents' overall skills and
knowledge, we selected 13 items for analysis a priori that we believed might
be affected by the presence of hospitalists. For comparison, we also examined
overall ratings of other rotations on which housestaff spent time both before
and after the reorganization in 1998, to allow detection of overall trends
in housestaff experience across the program as a whole. Each item was rated
on a 4- or 5-point Likert scale, higher being better.
Attending Survey
To assess the ratings of hospitalists as educators, we analyzed data
from an instrument filled out at the end of each rotation. In it, each house
officer rotating through general pediatrics provides an evaluation of each
attending physician's teaching and supervisory skills. Because housestaff
rotate through the service more than once, and because there are usually 2
attending physicians on service at a time, the number of possible evaluations
completed was greater than the number of residents in the program. In 1997-1998,
evaluations were completed on paper. In 1998-1999, a Web site–based
survey was piloted that replaced the paper instrument, but it was completed
by very few residents during this pilot phase; because of the very low numbers
of responses, we excluded 1998-1999 from the primary analysis. Throughout
1999-2000 residents completed the Web site–based survey.
This Web site–based survey was designed using Microsoft's Active
Server Pages (Microsoft Corp, Seattle, Wash) and was deployed on a Microsoft
Windows NT 4.0 Server computer, with collected data stored automatically to
a Microsoft Access database. The survey is only available for access within
the network firewall of the hospital. Access to the online survey is limited
to active housestaff only. Program directors and faculty in charge of each
clinical rotation have password-protected, real-time, online access to aggregate
survey results for the rotations they supervise.
To maintain confidentiality, attending physician identities were removed
from the data, but faculty evaluated in 1999-2000 were identified as hospitalists
or teaching attendings. Similarly, an identifier was left in place on the
1998 data to allow identification of all attending physicians who subsequently
became hospitalists. All 8 items present on both the 1997-1998 survey and
the 1999-2000 survey were analyzed. Each was rated using a 5-point Likert
scale (poor to excellent).
ANALYSIS
Responses of PGY1s and PGY3s were analyzed separately for the experiences
survey. A small number of combined medicine-pediatrics housestaff were excluded
from primary analysis, as we felt that their unique experience made grouping
them with other pediatric housestaff inappropriate. Ratings by PGY1s and PGY3
in 1997-1998 (before hospitalist system) were compared with ratings in 1998-1999
and 1999-2000 (after hospitalist system) using nonparametric Wilcoxon rank
sum tests. All results were confirmed in subsidiary analyses by dichotomizing
all survey items into best possible response vs all others, and reanalyzing
using Fisher exact tests.
On the attending survey, residents' ratings of hospitalists in 1999-2000
were compared with ratings of attending physicians in 1997-1998. We also looked
at ratings of the 1999-2000 teaching attendings as a concurrent comparison
group. The PGY1 and PGY3 responses were combined for attending survey analyses
because respondents' training levels were not identified on this survey. Wilcoxon
rank sum tests were used to compare each item on the attending survey. As
with the experiences survey, all results were validated by dichotomizing into
best possible response vs all others and reanalyzing using Fisher exact tests.
RESULTS
Seventy-six (70%) of the 109 PGY1s and 54 (62%) of the 87 PGY3s responded
to the annual experiences survey. Respondents in 1998, 1999, and 2000 did
not differ significantly by age or sex. Three hundred seventy-one (63%) of
the 593 attending physicians' surveys were completed.
OVERALL RATINGS
Following introduction of the hospitalist system and using a 5-point
Likert scale, interns' mean rating of the contribution of the general pediatrics
inpatient wards to their development of knowledge and skills rose from 4.1
points (of 5) in 1997-1998 to 4.7 points in 1999-2000 (P = .01) (Figure 1). Scoring
4.7 of 5 points, inpatient general pediatrics was the rotation most highly
rated by interns in 1999-2000, up from rank 6 of 12 before the introduction
of hospitalists. Ratings of none of the 11 comparison rotations changed significantly
between 1997-1998 and 1999-2000 (data not shown).
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Figure 1. Usefulness of general pediatrics
inpatient rotation. Asterisk indicates P<.05 vs 1998, Wilcoxon
nonparametric test; PGY1s, postgraduate year 1 interns; PGY3s, postgraduate
year 3 senior residents.
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Both before and after institution of the hospitalist system, senior
residents rated inpatient general pediatrics very highly (mean of 4.6 points
in 1997-1998 and 1999-2000) (Figure 1).
At 4.6 points, it was the second most highly rated of the 11 senior resident
rotations in 1999-2000 and the highest-ranked rotation of 1997-1998. Ratings
of none of the 10 comparison rotations changed significantly between 1997-1998
and 1999-2000 (data not shown).
THE PGY1 EXPERIENCE ON GENERAL PEDIATRICS WARDS AND SELF-ASSESSMENT
OF GENERAL PEDIATRICS KNOWLEDGE AND SKILLS
In addition to rating the general pediatrics rotation higher overall,
interns rated almost every aspect of their educational experience, supervision,
and quality of life on the general pediatrics wards higher on 4-point Likert
scales following introduction of the hospitalist system (Figure 2). From 1997-1998 to 1999-2000, ratings of overall educational
experience (3.2 vs 3.5 points, P<.05), degree
of autonomy in decision making (2.5 vs 3.3 points, P<.001),
amount of bedside teaching (1.7 vs 2.2 points, P<.01),
workload while on duty (2.2 vs 3.4 points, P<.001),
level of physical stress (2.0 vs 2.9 points, P<.01),
and level of psychological stress (1.9 vs 3.0 points, P<.001) all improved substantially, following more modest gains from
1997-1998 to 1998-1999. No items were rated lower.
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Figure 2. Postgraduate year 1 interns' satisfaction
with educational experience, supervision, and quality of life on general pediatrics
wards. Asterisk indicates P<.05 vs 1998, Wilcoxon nonparametric
test; dagger, P<.01; double dagger, P<.001;
and section mark, P<.001.
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Similarly, interns rated their opportunities to gain skills and knowledge
higher on 5-point Likert scales after introduction of the hospitalist system
(Figure 3). While these items reflected
experience in the program as a whole rather than experience on the general
pediatrics wards alone, we believed a priori that responses to these items
might be affected by the introduction of the hospitalists. From 1997-1998
to 1999-2000, ratings of generating a differential diagnosis (4.1 vs 4.6 points, P<.05), ability to make decisions independently (3.1
vs 4.1 points, P<.001), supervisory skills (2.7
vs 3.4 points, P<.05), and evaluating evidence
from the medical literature (2.5 vs 3.6 points, P<.001)
all improved. No items were rated lower.
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Figure 3. Skills and knowledge learned in
the residency program noted by postgraduate year 1 interns. Asterisk indicates P<.05 vs 1998, Wilcoxon nonparametric test; dagger, P<.001;
and double dagger, P<.01.
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THE PGY3 EXPERIENCE ON GENERAL PEDIATRICS WARDS AND SELF-ASSESSMENT
OF KNOWLEDGE AND SKILLS
Senior residents' experience was largely unchanged (Figure 4). On 4-point Likert scales, overall educational experience,
supervision by faculty, and amount of bedside teaching were rated much the
same after the hospitalist system as before. From 1997-1998 to 1999-2000 increases
in satisfaction with workload (2.7 vs 3.2 points, P
= .13), level of physical stress (2.1 vs 2.6 points, P
= .09), and level of psychological stress (2.1 vs 2.7 points, P = .12) were not statistically significant. Differences in ratings
of autonomy were not significant (3.4 vs 2.9 points, P
= .12).
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Figure 4. Postgraduate year 3 senior residents'
satisfaction with educational experience, supervision, and quality of life
on general pediatrics wards.
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Senior residents' ratings on 5-point Likert scales of their opportunities
to gain skills and knowledge were similarly unchanged overall (Figure 5). Though we found differences in ratings of ability to
make decisions independently (4.1 vs 3.5 points, P
= .07) and supervisory skills (4.2 vs 3.7 points, P
= .07), none were statistically significant.
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Figure 5. Skills and knowledge learned in
the residency program noted by postgraduate year 3 senior residents.
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RATINGS OF ATTENDING PHYSICIANS
Housestaff generally rated hospitalists' teaching and supervisory skills
higher than those of traditional attending physicians (Figure 6). In particular, hospitalists' overall teaching effectiveness
(4.7 vs 4.4 points, P<.01), effectiveness as role
models (4.7 vs 4.5 points, P<.05), feedback (4.5
vs 4.2 points, P<.01), involvement of housestaff
in the learning process (4.7 vs 4.4 points, P<.05),
accessibility (4.7 vs 4.5 points, P<.05), and
knowledge base (4.8 vs 4.5 points, P<.001) were
rated higher on 5-point Likert scales than those of nonhospitalist attending
physicians in 1997-1998. Hospitalists' bedside teaching, however, was rated
lower (3.7 vs 4.2 points, P<.001).
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Figure 6. Ratings of teaching and supervision
by attending physicians rated on a 5-point Likert scale. Asterisk indicates P<.01; dagger, P<.05 vs 1997-1998 attending physicians,
Wilcoxon nonparametric test; and section mark, P<.001.
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Ratings of 1999-2000 teaching attendings, by contrast, were not higher
than those of the 1997-1998 attending physicians. Their accessibility (4.1
vs 4.5 points, P<.01) and bedside teaching (3.9
vs 4.2 points, P<.05) were rated lower than their
historical counterparts; otherwise, they were rated similarly.
COMMENT
We found that interns rated their knowledge, skills, and experience
in inpatient general pediatrics higher after the introduction of hospitalists.
Senior residents' ratings, already quite high, were unchanged. We also found
that hospitalists were more likely than traditional attending physicians to
receive high ratings as role models and educators.
Prior work has suggested that time spent teaching improves the likelihood
that housestaff will identify attending physicians as excellent role models.
Wright et al18 found that attending physicians
spending more than 25% of their time teaching and those spending more than
25 hours per week teaching and conducting rounds when serving as an attending
physician were substantially more likely to be named excellent role models
by housestaff. Our study similarly finds an association between time on service
and ratings by housestaff, though 2 interpretations are possible.
It is possible that the high ratings of hospitalists were a function
of their extensive time on the wards. It is also possible, however, that hospitalists
received high ratings because they were already excellent teachers at the
time they began working as hospitalists. Secondary analyses comparing the
1999-2000 hospitalists with the small subset of 1997-1998 physicians who subsequently
became hospitalists suggest that both explanations are partially correct.
Although sample sizes were small, mean ratings of future hospitalists in 1997-1998
fell between the mean ratings of other 1997-1998 physicians and 1999-2000
hospitalists on 7 of 8 items (eg, overall teaching effectiveness 4.6 points
for future hospitalists vs 4.4 points for other 1997-1998 physicians and 4.7
points for 2000 hospitalists). Regardless of whether the key factor was selecting
the best teachers, increasing their experience, or increasing their availability,
however, we conclude that the hospitalist program facilitated provision of
an improved educational program. Moving to a hospitalist system made it possible
to place outstanding teachers on the wards for several months each throughout
the year.
Many secondary analyses were performed to test the validity of results.
Reanalysis of all items on the experiences survey after inclusion of the few
responses by combined medicine-pediatrics residents yielded no significant
differences. Analysis of the pilot Web site responses to the 1998-1999 attending
physicians' survey revealed that hospitalists in 1998-1999 received ratings
similar to hospitalists in 1999-2000, and teaching attendings in 1998-1999
received ratings similar to teaching attendings in 1999-2000. Use of alternative
statistical methods likewise yielded no important differences. On both the
experiences and attending survey, dichotomization of all items into best possible
response vs all others and analysis using the Fisher exact tests produced
results fundamentally similar to the Wilcoxon nonparametric comparisons.
The improved ratings of opportunities to evaluate evidence from the
medical literature deserve special mention. Objectives in implementing the
hospitalist system included improving and standardizing the quality of care
and bringing a stronger evidence base to bear on the treatment of pediatric
inpatients. While improvement on a single survey item should not be overinterpreted,
the improvement in interns' opportunities to use evidence-based medicine is
encouraging. Substantial room for improvement remains, however. Additional
efforts to provide a structured framework for the interpretation of data behind
inpatient management should continue to be a goal of hospitalist programs
to further improve the quality of medical education and decrease undesirable
variability in care, and the success of hospitalist systems in achieving this
goal should be tracked.
The Institute of Medicine recommends evidence-based medicine, shared
decision making with patients, and improved communication among clinicians
as key components of a health care system redesigned to improve quality.19 In particular, teamwork and open communication are
important in the reduction of medical errors.20
Medical educators have begun to address these issues.21-22
However, opportunities to model, teach, and measure these skills explicitly
in hospitalist systems and to redefine physician autonomy with respect to
these skills deserve further investigation.
The decrease in senior residents' ratings of their autonomy and supervisory
skills following introduction of the hospitalist system, although not statistically
significant, raises questions about the possible influence of hospitalists
on senior resident development of autonomy and supervisory skills. It is possible
that this hospitalist system exchanged some degree of senior resident autonomy
for improved communication and collaborative decision making between attending
physicians and housestaff. The concept of autonomy deserves further investigation,
and appropriate ways to teach and measure leadership and decision making while
optimizing teamwork and patient care should be examined.
Bedside teaching by hospitalists is an area of concern. The quality
of bedside teaching by hospitalists in 1999-2000 was rated lower than that
provided by attending physicians in 1997-1998. Housestaff rated their satisfaction
with the amount of bedside teaching quite low in both the traditional and
hospitalist systems. General pediatrics teams at the study hospital were large
in both systems (typically 11 physicians and medical students), and as a consequence,
relatively little bedside teaching has typically occurred during weekday work
rounds. Interventions that address this problem should be pursued.
The before and after design of this study has inherent limitations.
While we have identified an association between the institution of a hospitalist
system and improvements in housestaff ratings of their education and experience,
it is impossible to draw direct causal links between the introduction of the
hospitalist system and the changes observed. Changes in the residency program
and reorganizations of the medical service (eg, addition of new outpatient
subspecialty rotations and changes in subspecialty team organization) were
happening concurrently, and it is possible that these cointerventions rather
than the hospitalist system itself were responsible for the changes seen.
However for several reasons we believe these changes are unlikely to explain
our findings. First, we intentionally selected for analysis those items on
the experiences survey either specific to the general pediatrics inpatient
wards (Figure 2 and Figure 4) or believed a priori to be largely driven by the inpatient
general pediatrics experience (Figure 3
and Figure 5). Second, we found
no statistically significant changes in the overall ratings of any rotation
but the general pediatrics wards following the reorganization of the medical
services. If a hospitalwide factor, rather than one specific to general pediatrics,
was responsible for the widespread improvements on general pediatrics, significant
improvements would most likely have occurred on other rotations as well. Third,
we believe that the improved evaluations of hospitalists on the attending
survey are unlikely to have been driven by factors external to the hospitalist
system. The lack of improvement in ratings of the concurrent comparison group
(the teaching attendings) supports this assertion.
There were also changes to the interns' experience on the general pediatrics
teams themselves unrelated to hospitalist care, but, again, we do not believe
these changes would have led to the pattern of improvements seen. First, there
was a slight decrease in the average number of months housestaff spent in
inpatient general pediatrics per year, but we would have expected this change
to decrease educational opportunities in inpatient general pediatrics and
consequently to have lowered the ratings of educational opportunities. Second,
the average census on general pediatrics increased 7% from 1998 to 2000. If
changes in ratings of workload and quality of life were because of these shifts
in census, we would have expected housestaff to rate workload higher and quality
of life lower in 2000. Quite the contrary, interns rated their workload lower
and quality of life higher.
Because we studied a limited number of housestaff classes, we were concerned
that a cohort effect could be responsible for apparent changes. The interns
of 1997-1998 are the senior residents of 1999-2000. If this class tended to
rate all items lower than other classes, then the experience of interns would
artificially appear to have improved and that of senior residents to have
deteriorated from 1997-1998 to 1999-2000. This was not the case, however.
Interns' mean ratings of the 13 items on the experiences survey increased
an average of 0.71 points between 1997-1998 and 1999-2000, while senior residents'
ratings remained essentially unchanged (5% of the change in intern ratings).
While this does not rule out any cohort influence, it strongly suggests that
it is not the principal determinant of the changes seen.
This study adds to the emerging literature suggesting that hospitalist
systems have an overall positive effect on housestaff education and experience.
By evaluating specific aspects of the teaching and learning process, we gained
insights into the educational benefits of hospitalist programs and opportunities
for continued improvement. The differences in the reported experiences of
PGY1s and PGY3s will guide focused efforts to address the learning needs of
each. Future studies should also assess the influence of hospitalists on medical
student education. Beyond their effects on those aspects of education and
experience that we assessed in this study, it will also be important to understand
the influence of hospitalists on other aspects of trainees' experience and
training, including their clinical performance, procedure competency, documentation
patterns, and medical error rates.
A comprehensive assessment of a hospitalist system would include not
only a measurement of its effect on trainees but also an analysis of the influence
on other providers' and patients' experiences, efficiency of care, and quality
of care (as measured by both outcomes and processes of care), as well as an
analysis of the expected costs and the distribution of cost-benefits among
the various factions within the health care system.23
Such an analysis, however, was beyond the scope of this study.
In combined training and care systems, the pressures to maximize efficiency
and quality of clinical care are unlikely to abate. The use of hospitalist
systems is an increasingly widespread innovation shown to improve the efficiency
of care. As hospitalist systems evolve in academic centers, it will be important
to capture the new opportunities to improve physician training that these
systems offer so that improvements in teaching, care, and efficiency can be
made in concert.
| What This Study Adds
Hospitalist systems have been shown to decrease length of stay and inpatient
costs for adults and children, without adversely affecting mortality or readmission
rates. Their effect on housestaff experience and education, however, is not
well understood, particularly in pediatrics.
We found that interns' overall rating of general pediatrics ward rotations,
as well as ratings of almost all aspects of their education, experience, and
quality of life on the wards, improved significantly following the introduction
of a hospitalist system. Self-assessments of general pediatrics skills and
knowledge also improved. Senior residents' ratings, already quite high, remained
unchanged. In addition, housestaff rated the overall quality of teaching and
most specific aspects of teaching and supervision higher for hospitalists
than for traditional attending physicians, although bedside teaching was rated
lower. These findings support the adoption of hospitalist systems by academic
pediatric programs and should help guide educational improvement efforts in
academic hospitalist systems.
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AUTHOR INFORMATION
Accepted for publication April 10, 2002.
This study was supported in part by grantT32 PE10018 from the Health
Resources and Services Administration, Rockville, Md, to the Harvard Pediatric
Health Services Research Fellowship Program (Dr Landrigan).
We thank Paul Lerou, MD, and Joshua Nagler, MD, for their review of
the manuscript and helpful comments.
Corresponding author and reprints: Christopher Landrigan, MD, MPH,
Children's Hospital, Main 10E, Room 1032.2, 300 Longwood Ave, Boston, MA 02115
(e-mail: landrigan_c{at}hub.tch.harvard.edu).
From the Department of Medicine, Children's Hospital (Drs Landrigan,
Muret-Wagstaff, Chiang, Nigrin, Goldmann, and Finkelstein), and the Departments
of Pediatrics (Drs Landrigan, Muret-Wagstaff, Chiang, Nigrin, Goldmann, and
Finkelstein) and Ambulatory Care and Prevention (Dr Finkelstein), Harvard
Medical School, Boston, Mass.
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