Deborah Kees‐Folts, MD

In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4

Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13

The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.

METHODS

RESULTS

All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.

The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).

Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).

DISCUSSION

Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.

It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.

Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.

Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27

In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.

In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4

Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13

The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.

METHODS

RESULTS

All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.

The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).

Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).

DISCUSSION

Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.

It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.

Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.

Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27

In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.

In 1996 Wachter and Goldman anticipated the emergence of hospitalists,1 physicians who are responsible for the care of hospitalized patients in place of their primary care physicians. The number of physicians who identify themselves as hospitalists has grown rapidly since 1996 and is currently estimated to be 10,00012,000, with the potential to reach as high as 30,000 in the next decade.2 This growth includes academic medical centers. In surveys of chairs of internal medicine and pediatric departments, 50% have hospitalists employed at their institutions.3, 4

Hospitalists in academic institutions are playing an increasingly prominent role in the medical education of both residents and medical students. The implications of adopting a hospitalist model on medical education has been discussed.57 Despite such concerns as fragmented continuity of care; decreased exposure to primary care physicians, subspecialists and physician‐scientists; reduced autonomy; and fewer educational opportunities to observe the natural histories of illnesses because of improved efficiency,57 the overall impact of hospitalists on medical and resident education has generally been favorable.818 Internal medicine residents have rated the teaching skills of hospitalists comparable to traditional academic physicians,8, 9 and believe the addition of hospitalists has contributed to an improved educational experience.10, 11, 14 In addition, a survey of third‐year medical students at a single academic teaching hospital concluded that hospitalists were able to provide at least as positive an educational experience during their inpatient medicine rotations as highly rated nonhospitalist teaching faculty.13

The role of hospitalists as educators in pediatrics has been studied much less. Pediatric resident satisfaction has improved in institutions that have used a hospitalist model.1618 In another study, hospitalists were rated by pediatric residents as more effective teachers than nonhospitalists.15 Because we are unaware of any study that has evaluated hospitalists in the education of medical students during their inpatient pediatric rotation, the purpose of our study was to compare hospitalist and nonhospitalist faculty on the educational experience of third‐year medical students during the inpatient portion of their pediatric clerkships at a single university children's hospital.

METHODS

RESULTS

All 67 of the students who completed a pediatrics clerkship at PSCH returned evaluation forms, which were the data for further analysis. Thirty‐five students rotated with the hospitalist faculty, and 32 students rotated with the nonhospitalist faculty. There were no significant demographic differences between the hospitalist and nonhospitalist faculty in age, sex, academic rank, specialty, and years since completing training (Table 2). All the hospitalist faculty fulfilled the definition of a hospitalist,2 whereas none of the physicians in the nonhospitalist group did.

The hospitalists were rated significantly higher than the nonhospitalist faculty in all 4 of the attending characteristics measured (Table 1): teaching effectiveness (3.87 vs. 2.91; P < .0001), effectiveness as a pediatrician (3.94 vs. 3.25; P < .001), student advocacy effectiveness (3.76 vs. 2.97; P < .0001), and overall evaluation (3.93 vs. 3.06; P < .001).

Analysis of specific aspects of the rotation showed the only feature that hospitalists were rated significantly higher on was quality of ward rounds (3.15 vs. 2.58, P < .006). There was no significant difference between the hospitalists and nonhospitalists on features that were not specifically part of the inpatient rotation, including various conferences, outpatient clinics, and newborn care (Table 1).

DISCUSSION

Our study demonstrates that pediatric hospitalists had a positive impact on the overall educational experience of third‐year medical students during the inpatient portions of their pediatrics clerkships. Hospitalists were rated more favorably than nonhospitalists as teachers, as pediatricians, as student advocates, and overall. Medical students also rated the value of ward rounds more favorably when hospitalists conducted them. In addition, higher percentages of nonhospitalists than hospitalists were rated as adequate or inadequate for the above items. When other aspects of the clerkship were analyzed, there were no statistically significant differences between the students who rotated with hospitalists and the students who rotated with nonhospitalists. This suggests that the higher scores for hospitalists were specifically related to their interactions with students, rather than with an overall more positive view of the rotation.

It has been suggested that forces promoting the use of hospitalists in adult medicine are even more persuasive in the pediatric population, as the difference in severity of illness between the inpatient and outpatient setting is greater, and the average pediatrician has less experience than the average internist in managing hospitalized patients.19 In a recent systematic review of the literature, Landrigan et al.20 reported that 6 of 7 studies demonstrated hospitalist systems had decreased hospital length of stay compared to systems in which a primary pediatrician served as the physician of record. This improved efficiency, if combined with the pressure to see more patients while trying to balance teaching and research demands, may have a negative impact on the quality of medical education.

Several factors may have contributed to the students' satisfaction with hospitalists. Studies have demonstrated that students rate clinical teachers more favorably with whom they have greater involvement.21 Hospitalists may be more likely to spend time on the inpatient wards given that is the primary site of their clinical activity. This increased presence may have contributed to more favorable evaluations for the hospitalist faculty, whereas the additional outpatient workload for nonhospitalist faculty may have reduced inpatient teaching opportunities, accounting for their lower teaching score. Included in the pediatrician category was the attribute of being a role model. In a study by Wright et al.,22 spending more than 25% of the time or 25 or more hours per week teaching and conducting rounds was independently associated with being considered an excellent role model. Again, the increased availability of the hospitalists on the inpatient wards may have led to more teaching opportunities, contributing to their higher score.

Our study had several limitations. First, it was a retrospective study conducted at a single institution with only 2 hospitalists. Although there were not statistical significant demographic differences between the 2 groups, this may simply reflect the small size of the sample in our study; therefore, the results may not be applicable to other academic institutions. Second, we retrospectively analyzed an evaluation form that had not been validated or specifically designed to compare 2 physician groups. Third, there were multiple statements in each category that students were asked to consider before scoring each attending on the parameters measured. Although hospitalists were rated higher in each category, there may have been individual characteristics within each category for which the nonhospitalist faculty performed better. Fourth, although hospitalists received higher average ratings than nonhospitalist faculty from third‐year medical students, it is important to emphasize this study measured students' attitudes and beliefs not specific educational outcomes. However, even though we cannot rule out the possibility that potentially confounding factors such as the personality of an attending physician influenced the results, prior studies have demonstrated that medical students make sophisticated judgments about teaching in the clinical setting.23, 24 It is unlikely that hospitalists at our institution were specifically selected to attend more months on a new inpatient service because they had a history of having more favorable teaching qualities because 1 of the 2 hospitalists had just finished residency training, and there were no significant demographic differences between the 2 groups. In a study examining trainee satisfaction in an internal medicine rotation 4 years after adoption of a hospitalist model, where nonhospitalist faculty attended based on their own interest and inpatient skill rather than as a requirement, Hauer et al.14 reported that trainees experienced more effective teaching and a more satisfying inpatient rotation when supervised by hospitalists. This suggests that hospitalists may possess or develop a specific inpatient knowledge base and teaching acumen over time that distinguishes them from nonhospitalists. There is evidence of accumulated experience leading to improved outcomes in the clinical setting for HIV infection,25 various surgical procedures,26 and hospitalist systems.27

In conclusion, this is the first study to evaluate the performance of hospitalists in the setting of a third‐year medical student pediatrics clerkship. Although third‐year medical students rate hospitalists at least as highly as nonhospitalist faculty, further studies are needed to reproduce this finding. In addition to the increased time spent on the wards with students and increased experience in caring for hospitalized patients, further studies should also examine the role that communication plays in clinical teaching. Also, the recent development of core competencies in hospital medicine28 may lead to the development of educational outcomes that can be objectively measured.