Karen E. Hauer, MD

Nearly half of the hospital beds in the United States are occupied by the elderly,1 whose numbers are increasing.2 The odds of a hospitalized Medicare patient being cared for by a hospitalist are increasing by nearly 30% per year.3 Hospitalists require competence in geriatrics to serve their patients and to teach trainees. Train‐the‐Trainer (TTT) programs both educate health care providers and provide educational materials, information, and skills for teaching others.4 This model has been successfully used in geriatrics to impact knowledge, attitudes, and self‐efficacy among health care workers.46

A prominent example of a geriatrics TTT program is the University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP),7 which requires 48 hours of instruction over 12 sessions. To create a less time‐intensive learning format for busy hospitalists, the University of Chicago developed Mini‐CHAMP, a streamlined 2‐day workshop with web‐based components for hospitalist clinicians, but not necessarily hospitalist educators.7

We created The Donald W. Reynolds Program for Advancing Geriatrics Education (PAGE) at the University of California, San Francisco (UCSF), in light of the time intensity of CHAMP, to integrate geriatric TTT sessions within preexisting hospitalist faculty meetings. This model is consistent with current practices in faculty development.8 This paper describes the evaluation of the PAGE Model, which sought answers to 3 research questions: (1) Does PAGE increase faculty confidence in teaching geriatrics?, (2) Does PAGE increase the frequency of hospitalist teaching geriatrics topics?, and (3) Does PAGE increase residents' practice of geriatrics skills?

Methods

Results

The hospitalist group grew from 31 to 36 members in June of 2008. On average, 14 hospitalists (M = 14.40, standard deviation [SD] = 2.41, range 1119) attended each session, with all hospitalists (n = 36) attending 1 session (M = 3.83, SD = 2.35, range 19). At each session, an average of 72% completed a post‐session evaluation form. Overall, faculty were likely to use the PAGE teaching tools (M = 4.61, SD = 0.53) and would recommend PAGE to other hospitalists (M = 4.63, SD = 0.51).

Thirteen hospitalist trainees of 36 (36%) completed a post‐PAGE online questionnaire. Respondents taught on faculty for an average of 5 years (mean (M) = 5.08, SD = 3.52). Faculty perceived self‐efficacy at teaching residents about geriatrics improved significantly with a large effect size (pretest M = 3.05, SD = .60; posttest M = 3.96, SD = .36, d = 1.52; P < 0.001). Session attendance was positively correlated with the increase in geriatrics teaching self‐efficacy (r = .62, P < 0.05), while teaching experience was not (r = 0.05, P = 0.88). Hospitalist trainees found the PAGE model more useful after participating (M = 4.62, SD = 0.65), than they had expected (M = 3.92, SD = 0.76; P < 0.05).

All session leaders (n = 15) completed the questionnaire after PAGE (9 hospitalists, 5 geriatricians, 1 urologist). Two‐thirds had 5 years on faculty; eight had no prior experience as a faculty development trainer. Over 80% indicated that they found their coteaching experience, enjoyable, useful and collaborative. Only 1 participant did not commit to interdisciplinary teaching again. Most hospitalist session leaders reported that coteaching with a geriatrician enhanced their knowledge; they were more likely to consult a geriatrician regarding patients. All but 2 session leaders felt that the model fostered a collaborative environment between their 2 divisions.

Of the 56 residents, 41% (16 PGY1, 7 PGY2) completed a pretest; 43% (15 PGY1, 9 PGY2) completed a posttest. Residents reported receiving inpatient teaching on geriatrics skills significantly more frequently from hospitalists vs. nonhospitalist attendings both before PAGE (hospitalists M = 2.18, SD = 0.37; nonhospitalists M = 2.00, SD = 0.53, P < 0.05), and after (hospitalists M = 2.39, SD = 0.46; nonhospitalists M = 2.05, SD = 0.57, P < 0.05; see Fig. 1). Although hospitalists taught more frequently about geriatrics than nonhospitalists before PAGE, our findings suggest that they increased their teaching by a greater magnitude than nonhospitalists (P < 0.01, P > 0.05, respectively). Residents reported increased geriatric skill practice after PAGE with a medium effect size (pretest M = 2.92, SD = 0.55, posttest M = 3.28, SD = 0.66, P = 0.052, d = 0.66). There was greater mean reported practice for all skills with the exception of hospice care, which already was being performed between often and very often before PAGE. The largest increases in skill practice were (descending order, most increased first): assessing polypharmacy, performing skin exams, prognostication, performing functional assessments and examining Foley catheter use.

Figure 1

Discussion

Our aging population and a shortage of geriatricians necessitates new, feasible models for geriatric training. Similar to the CHAMP model,7 PAGE had a favorable impact on faculty perceived behavioral change; after the PAGE sessions, faculty reported significantly greater self‐efficacy of teaching geriatrics. However, this study also examined the impact of the PAGE Model on 2 groups not previously reported in the literature: faculty session leaders and medicine residents.

To our knowledge, this is the first study about a hospitalist TTT program codeveloped with nonhospitalists aimed at teaching geriatrics skills to residents, though smaller scale programs for medical students exist.24 We believe codevelopment was important in our model for many reasons. First, using hospitalist peers and local geriatricians likely increased trust in the educational curricula and allowed for strong communication channels between instructors.25, 26 Second, coteaching allowed for hospitalist mentorship. Hospitalists acknowledged their coleaders as mentors and several hospitalists subsequently engaged in new geriatric projects. Third, coteaching was felt to enhance patient care and increase geriatrician consultations. Coteaching may have applicability to other hospitalist faculty development such as intensive care and palliative care, and hospitalist programs may benefit from creating faculty development programs internally with their colleagues, rather than using online resources.

Another important finding of this study is that training hospitalists to teach about geriatrics seems to result in an increase in both the geriatric teaching that residents receive and residents' practice of geriatric skills. This outcome has not been previously demonstrated with geriatric TTT activities.27 This trickle‐down effect to residents likely results from both the increased teaching efficacy of hospitalists after the PAGE Model and the exportable nature of the teaching tools.

Several continuing medical education best practices were used which we believe contributed to the success of PAGE. First, we conducted a needs assessment, which improves knowledge outcomes.28, 29 Second, sessions included cases, lectures, and discussions. Use of multiple educational techniques yields greater knowledge and behavioral change as compared to a single method, such as lecture alone.24, 25, 30, 31 Finally, sessions were sequenced over a year, rather than clustered in short, intensive activity. Sequenced, or learn‐work‐learn opportunities allow education to be translated to practice and reinforced.8, 27, 30, 32

We believe that the PAGE Model is transportable to other hospitalist programs due to its cost and flexible nature. In economically‐lean times, hospitalist divisions can create a program similar to the PAGE Model essentially at no cost, except for donated faculty preparation time. In contrast, CHAMP was expensive, costing nearly $72,000 for 12 faculty to participate in the 48‐hour curriculum,7, 33 and volunteering physicians were compensated for their time. Though Mini‐CHAMP is a streamlined 2‐day workshop that offers free online lectures and slide sets, there may be some benefit to producing a faculty development program internally, as we stated above, and PAGE included additional topics (urinary catheters and decubitus ulcers/wound care) not covered in mini‐CHAMP.

There were several limitations to this study. First, some outcomes of the PAGE Model were assessed by retrospective self‐report, which may allow for recall bias. Although self‐report may or may not correlate with actual behavior,34 faculty and resident perspectives of their teaching and learning experiences are themselves important. Furthermore, a retrospective presurvey allows for content of an educational program or intervention to be explained prior to a survey, so that participants first assess their new level of understanding or skill on the post test, then reflectively assess the level of understanding or skill they had prior to the workshop. This avoids response shift bias and can improve internal validity.21, 35

Second, the small numbers of session leaders, hospitalist trainees, and residents restricted statistical power to detect small effects. The fact that we found significant improvements enhances the likelihood that the differences observed were not due to chance.

Third, the low response rates from the hospitalist trainee post‐intervention questionnaire and the residents' questionnaires may affect the validity of our results. For the resident survey, the subjects were not matched, and we cannot state that an individual's geriatric skill practice changed due to PAGE, though the results suggest the residency program as a whole improved the frequency of geriatric skill practice.

Finally, the residents were required to report the frequency of teaching on and practice of geriatric skills practice over the prior year and accuracy of recall may be an issue. However, frequencies were queried both pre and post intervention and favorable change was noted. Furthermore, because the high end of the 3‐point teaching scale was limited to more than once, the true amount of teaching may have been underestimated if more than once actually represented high frequencies.

Future studies are needed to replicate these findings at other institutions to confirm generalizability. It would be beneficial to measure patient outcomes to determine whether increased teaching and skill practice benefits patients using measures such as reduction in catheter related urinary tract infections, falls, and inadequate pain management. Further investigations of cotaught faculty development programs between hospitalists and other specialists help emphasize why internally created TTT programs are of greater value than online resources.

Conclusions

This time‐sensitive adaptation of a hospitalist geriatric TTT program was successfully implemented at an academic medical center and suggests improved hospitalist faculty self‐efficacy at teaching geriatric skills, increased frequency of inpatient geriatric teaching by hospitalists and increased resident geriatric skill practice. Confidence to care for geriatric patients and a strong skill set to assess risks and manage them appropriately will equip hospitalists and trainees to provide care that reduces geriatric patients' in‐hospital morbidity and costs of care. As hospitalists increasingly care for older adults, the need for time‐efficient methods of teaching geriatrics will continue to grow. The PAGE Model, and other new models of geriatric training for hospitalists, demonstrates that we are beginning to address this urgent need.

Nearly half of the hospital beds in the United States are occupied by the elderly,1 whose numbers are increasing.2 The odds of a hospitalized Medicare patient being cared for by a hospitalist are increasing by nearly 30% per year.3 Hospitalists require competence in geriatrics to serve their patients and to teach trainees. Train‐the‐Trainer (TTT) programs both educate health care providers and provide educational materials, information, and skills for teaching others.4 This model has been successfully used in geriatrics to impact knowledge, attitudes, and self‐efficacy among health care workers.46

A prominent example of a geriatrics TTT program is the University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP),7 which requires 48 hours of instruction over 12 sessions. To create a less time‐intensive learning format for busy hospitalists, the University of Chicago developed Mini‐CHAMP, a streamlined 2‐day workshop with web‐based components for hospitalist clinicians, but not necessarily hospitalist educators.7

We created The Donald W. Reynolds Program for Advancing Geriatrics Education (PAGE) at the University of California, San Francisco (UCSF), in light of the time intensity of CHAMP, to integrate geriatric TTT sessions within preexisting hospitalist faculty meetings. This model is consistent with current practices in faculty development.8 This paper describes the evaluation of the PAGE Model, which sought answers to 3 research questions: (1) Does PAGE increase faculty confidence in teaching geriatrics?, (2) Does PAGE increase the frequency of hospitalist teaching geriatrics topics?, and (3) Does PAGE increase residents' practice of geriatrics skills?

Methods

Results

The hospitalist group grew from 31 to 36 members in June of 2008. On average, 14 hospitalists (M = 14.40, standard deviation [SD] = 2.41, range 1119) attended each session, with all hospitalists (n = 36) attending 1 session (M = 3.83, SD = 2.35, range 19). At each session, an average of 72% completed a post‐session evaluation form. Overall, faculty were likely to use the PAGE teaching tools (M = 4.61, SD = 0.53) and would recommend PAGE to other hospitalists (M = 4.63, SD = 0.51).

Thirteen hospitalist trainees of 36 (36%) completed a post‐PAGE online questionnaire. Respondents taught on faculty for an average of 5 years (mean (M) = 5.08, SD = 3.52). Faculty perceived self‐efficacy at teaching residents about geriatrics improved significantly with a large effect size (pretest M = 3.05, SD = .60; posttest M = 3.96, SD = .36, d = 1.52; P < 0.001). Session attendance was positively correlated with the increase in geriatrics teaching self‐efficacy (r = .62, P < 0.05), while teaching experience was not (r = 0.05, P = 0.88). Hospitalist trainees found the PAGE model more useful after participating (M = 4.62, SD = 0.65), than they had expected (M = 3.92, SD = 0.76; P < 0.05).

All session leaders (n = 15) completed the questionnaire after PAGE (9 hospitalists, 5 geriatricians, 1 urologist). Two‐thirds had 5 years on faculty; eight had no prior experience as a faculty development trainer. Over 80% indicated that they found their coteaching experience, enjoyable, useful and collaborative. Only 1 participant did not commit to interdisciplinary teaching again. Most hospitalist session leaders reported that coteaching with a geriatrician enhanced their knowledge; they were more likely to consult a geriatrician regarding patients. All but 2 session leaders felt that the model fostered a collaborative environment between their 2 divisions.

Of the 56 residents, 41% (16 PGY1, 7 PGY2) completed a pretest; 43% (15 PGY1, 9 PGY2) completed a posttest. Residents reported receiving inpatient teaching on geriatrics skills significantly more frequently from hospitalists vs. nonhospitalist attendings both before PAGE (hospitalists M = 2.18, SD = 0.37; nonhospitalists M = 2.00, SD = 0.53, P < 0.05), and after (hospitalists M = 2.39, SD = 0.46; nonhospitalists M = 2.05, SD = 0.57, P < 0.05; see Fig. 1). Although hospitalists taught more frequently about geriatrics than nonhospitalists before PAGE, our findings suggest that they increased their teaching by a greater magnitude than nonhospitalists (P < 0.01, P > 0.05, respectively). Residents reported increased geriatric skill practice after PAGE with a medium effect size (pretest M = 2.92, SD = 0.55, posttest M = 3.28, SD = 0.66, P = 0.052, d = 0.66). There was greater mean reported practice for all skills with the exception of hospice care, which already was being performed between often and very often before PAGE. The largest increases in skill practice were (descending order, most increased first): assessing polypharmacy, performing skin exams, prognostication, performing functional assessments and examining Foley catheter use.

Figure 1

Discussion

Our aging population and a shortage of geriatricians necessitates new, feasible models for geriatric training. Similar to the CHAMP model,7 PAGE had a favorable impact on faculty perceived behavioral change; after the PAGE sessions, faculty reported significantly greater self‐efficacy of teaching geriatrics. However, this study also examined the impact of the PAGE Model on 2 groups not previously reported in the literature: faculty session leaders and medicine residents.

To our knowledge, this is the first study about a hospitalist TTT program codeveloped with nonhospitalists aimed at teaching geriatrics skills to residents, though smaller scale programs for medical students exist.24 We believe codevelopment was important in our model for many reasons. First, using hospitalist peers and local geriatricians likely increased trust in the educational curricula and allowed for strong communication channels between instructors.25, 26 Second, coteaching allowed for hospitalist mentorship. Hospitalists acknowledged their coleaders as mentors and several hospitalists subsequently engaged in new geriatric projects. Third, coteaching was felt to enhance patient care and increase geriatrician consultations. Coteaching may have applicability to other hospitalist faculty development such as intensive care and palliative care, and hospitalist programs may benefit from creating faculty development programs internally with their colleagues, rather than using online resources.

Another important finding of this study is that training hospitalists to teach about geriatrics seems to result in an increase in both the geriatric teaching that residents receive and residents' practice of geriatric skills. This outcome has not been previously demonstrated with geriatric TTT activities.27 This trickle‐down effect to residents likely results from both the increased teaching efficacy of hospitalists after the PAGE Model and the exportable nature of the teaching tools.

Several continuing medical education best practices were used which we believe contributed to the success of PAGE. First, we conducted a needs assessment, which improves knowledge outcomes.28, 29 Second, sessions included cases, lectures, and discussions. Use of multiple educational techniques yields greater knowledge and behavioral change as compared to a single method, such as lecture alone.24, 25, 30, 31 Finally, sessions were sequenced over a year, rather than clustered in short, intensive activity. Sequenced, or learn‐work‐learn opportunities allow education to be translated to practice and reinforced.8, 27, 30, 32

We believe that the PAGE Model is transportable to other hospitalist programs due to its cost and flexible nature. In economically‐lean times, hospitalist divisions can create a program similar to the PAGE Model essentially at no cost, except for donated faculty preparation time. In contrast, CHAMP was expensive, costing nearly $72,000 for 12 faculty to participate in the 48‐hour curriculum,7, 33 and volunteering physicians were compensated for their time. Though Mini‐CHAMP is a streamlined 2‐day workshop that offers free online lectures and slide sets, there may be some benefit to producing a faculty development program internally, as we stated above, and PAGE included additional topics (urinary catheters and decubitus ulcers/wound care) not covered in mini‐CHAMP.

There were several limitations to this study. First, some outcomes of the PAGE Model were assessed by retrospective self‐report, which may allow for recall bias. Although self‐report may or may not correlate with actual behavior,34 faculty and resident perspectives of their teaching and learning experiences are themselves important. Furthermore, a retrospective presurvey allows for content of an educational program or intervention to be explained prior to a survey, so that participants first assess their new level of understanding or skill on the post test, then reflectively assess the level of understanding or skill they had prior to the workshop. This avoids response shift bias and can improve internal validity.21, 35

Second, the small numbers of session leaders, hospitalist trainees, and residents restricted statistical power to detect small effects. The fact that we found significant improvements enhances the likelihood that the differences observed were not due to chance.

Third, the low response rates from the hospitalist trainee post‐intervention questionnaire and the residents' questionnaires may affect the validity of our results. For the resident survey, the subjects were not matched, and we cannot state that an individual's geriatric skill practice changed due to PAGE, though the results suggest the residency program as a whole improved the frequency of geriatric skill practice.

Finally, the residents were required to report the frequency of teaching on and practice of geriatric skills practice over the prior year and accuracy of recall may be an issue. However, frequencies were queried both pre and post intervention and favorable change was noted. Furthermore, because the high end of the 3‐point teaching scale was limited to more than once, the true amount of teaching may have been underestimated if more than once actually represented high frequencies.

Future studies are needed to replicate these findings at other institutions to confirm generalizability. It would be beneficial to measure patient outcomes to determine whether increased teaching and skill practice benefits patients using measures such as reduction in catheter related urinary tract infections, falls, and inadequate pain management. Further investigations of cotaught faculty development programs between hospitalists and other specialists help emphasize why internally created TTT programs are of greater value than online resources.

Conclusions

This time‐sensitive adaptation of a hospitalist geriatric TTT program was successfully implemented at an academic medical center and suggests improved hospitalist faculty self‐efficacy at teaching geriatric skills, increased frequency of inpatient geriatric teaching by hospitalists and increased resident geriatric skill practice. Confidence to care for geriatric patients and a strong skill set to assess risks and manage them appropriately will equip hospitalists and trainees to provide care that reduces geriatric patients' in‐hospital morbidity and costs of care. As hospitalists increasingly care for older adults, the need for time‐efficient methods of teaching geriatrics will continue to grow. The PAGE Model, and other new models of geriatric training for hospitalists, demonstrates that we are beginning to address this urgent need.

Nearly half of the hospital beds in the United States are occupied by the elderly,1 whose numbers are increasing.2 The odds of a hospitalized Medicare patient being cared for by a hospitalist are increasing by nearly 30% per year.3 Hospitalists require competence in geriatrics to serve their patients and to teach trainees. Train‐the‐Trainer (TTT) programs both educate health care providers and provide educational materials, information, and skills for teaching others.4 This model has been successfully used in geriatrics to impact knowledge, attitudes, and self‐efficacy among health care workers.46

A prominent example of a geriatrics TTT program is the University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP),7 which requires 48 hours of instruction over 12 sessions. To create a less time‐intensive learning format for busy hospitalists, the University of Chicago developed Mini‐CHAMP, a streamlined 2‐day workshop with web‐based components for hospitalist clinicians, but not necessarily hospitalist educators.7

We created The Donald W. Reynolds Program for Advancing Geriatrics Education (PAGE) at the University of California, San Francisco (UCSF), in light of the time intensity of CHAMP, to integrate geriatric TTT sessions within preexisting hospitalist faculty meetings. This model is consistent with current practices in faculty development.8 This paper describes the evaluation of the PAGE Model, which sought answers to 3 research questions: (1) Does PAGE increase faculty confidence in teaching geriatrics?, (2) Does PAGE increase the frequency of hospitalist teaching geriatrics topics?, and (3) Does PAGE increase residents' practice of geriatrics skills?

Methods

Results

The hospitalist group grew from 31 to 36 members in June of 2008. On average, 14 hospitalists (M = 14.40, standard deviation [SD] = 2.41, range 1119) attended each session, with all hospitalists (n = 36) attending 1 session (M = 3.83, SD = 2.35, range 19). At each session, an average of 72% completed a post‐session evaluation form. Overall, faculty were likely to use the PAGE teaching tools (M = 4.61, SD = 0.53) and would recommend PAGE to other hospitalists (M = 4.63, SD = 0.51).

Thirteen hospitalist trainees of 36 (36%) completed a post‐PAGE online questionnaire. Respondents taught on faculty for an average of 5 years (mean (M) = 5.08, SD = 3.52). Faculty perceived self‐efficacy at teaching residents about geriatrics improved significantly with a large effect size (pretest M = 3.05, SD = .60; posttest M = 3.96, SD = .36, d = 1.52; P < 0.001). Session attendance was positively correlated with the increase in geriatrics teaching self‐efficacy (r = .62, P < 0.05), while teaching experience was not (r = 0.05, P = 0.88). Hospitalist trainees found the PAGE model more useful after participating (M = 4.62, SD = 0.65), than they had expected (M = 3.92, SD = 0.76; P < 0.05).

All session leaders (n = 15) completed the questionnaire after PAGE (9 hospitalists, 5 geriatricians, 1 urologist). Two‐thirds had 5 years on faculty; eight had no prior experience as a faculty development trainer. Over 80% indicated that they found their coteaching experience, enjoyable, useful and collaborative. Only 1 participant did not commit to interdisciplinary teaching again. Most hospitalist session leaders reported that coteaching with a geriatrician enhanced their knowledge; they were more likely to consult a geriatrician regarding patients. All but 2 session leaders felt that the model fostered a collaborative environment between their 2 divisions.

Of the 56 residents, 41% (16 PGY1, 7 PGY2) completed a pretest; 43% (15 PGY1, 9 PGY2) completed a posttest. Residents reported receiving inpatient teaching on geriatrics skills significantly more frequently from hospitalists vs. nonhospitalist attendings both before PAGE (hospitalists M = 2.18, SD = 0.37; nonhospitalists M = 2.00, SD = 0.53, P < 0.05), and after (hospitalists M = 2.39, SD = 0.46; nonhospitalists M = 2.05, SD = 0.57, P < 0.05; see Fig. 1). Although hospitalists taught more frequently about geriatrics than nonhospitalists before PAGE, our findings suggest that they increased their teaching by a greater magnitude than nonhospitalists (P < 0.01, P > 0.05, respectively). Residents reported increased geriatric skill practice after PAGE with a medium effect size (pretest M = 2.92, SD = 0.55, posttest M = 3.28, SD = 0.66, P = 0.052, d = 0.66). There was greater mean reported practice for all skills with the exception of hospice care, which already was being performed between often and very often before PAGE. The largest increases in skill practice were (descending order, most increased first): assessing polypharmacy, performing skin exams, prognostication, performing functional assessments and examining Foley catheter use.

Figure 1

Discussion

Our aging population and a shortage of geriatricians necessitates new, feasible models for geriatric training. Similar to the CHAMP model,7 PAGE had a favorable impact on faculty perceived behavioral change; after the PAGE sessions, faculty reported significantly greater self‐efficacy of teaching geriatrics. However, this study also examined the impact of the PAGE Model on 2 groups not previously reported in the literature: faculty session leaders and medicine residents.

To our knowledge, this is the first study about a hospitalist TTT program codeveloped with nonhospitalists aimed at teaching geriatrics skills to residents, though smaller scale programs for medical students exist.24 We believe codevelopment was important in our model for many reasons. First, using hospitalist peers and local geriatricians likely increased trust in the educational curricula and allowed for strong communication channels between instructors.25, 26 Second, coteaching allowed for hospitalist mentorship. Hospitalists acknowledged their coleaders as mentors and several hospitalists subsequently engaged in new geriatric projects. Third, coteaching was felt to enhance patient care and increase geriatrician consultations. Coteaching may have applicability to other hospitalist faculty development such as intensive care and palliative care, and hospitalist programs may benefit from creating faculty development programs internally with their colleagues, rather than using online resources.

Another important finding of this study is that training hospitalists to teach about geriatrics seems to result in an increase in both the geriatric teaching that residents receive and residents' practice of geriatric skills. This outcome has not been previously demonstrated with geriatric TTT activities.27 This trickle‐down effect to residents likely results from both the increased teaching efficacy of hospitalists after the PAGE Model and the exportable nature of the teaching tools.

Several continuing medical education best practices were used which we believe contributed to the success of PAGE. First, we conducted a needs assessment, which improves knowledge outcomes.28, 29 Second, sessions included cases, lectures, and discussions. Use of multiple educational techniques yields greater knowledge and behavioral change as compared to a single method, such as lecture alone.24, 25, 30, 31 Finally, sessions were sequenced over a year, rather than clustered in short, intensive activity. Sequenced, or learn‐work‐learn opportunities allow education to be translated to practice and reinforced.8, 27, 30, 32

We believe that the PAGE Model is transportable to other hospitalist programs due to its cost and flexible nature. In economically‐lean times, hospitalist divisions can create a program similar to the PAGE Model essentially at no cost, except for donated faculty preparation time. In contrast, CHAMP was expensive, costing nearly $72,000 for 12 faculty to participate in the 48‐hour curriculum,7, 33 and volunteering physicians were compensated for their time. Though Mini‐CHAMP is a streamlined 2‐day workshop that offers free online lectures and slide sets, there may be some benefit to producing a faculty development program internally, as we stated above, and PAGE included additional topics (urinary catheters and decubitus ulcers/wound care) not covered in mini‐CHAMP.

There were several limitations to this study. First, some outcomes of the PAGE Model were assessed by retrospective self‐report, which may allow for recall bias. Although self‐report may or may not correlate with actual behavior,34 faculty and resident perspectives of their teaching and learning experiences are themselves important. Furthermore, a retrospective presurvey allows for content of an educational program or intervention to be explained prior to a survey, so that participants first assess their new level of understanding or skill on the post test, then reflectively assess the level of understanding or skill they had prior to the workshop. This avoids response shift bias and can improve internal validity.21, 35

Second, the small numbers of session leaders, hospitalist trainees, and residents restricted statistical power to detect small effects. The fact that we found significant improvements enhances the likelihood that the differences observed were not due to chance.

Third, the low response rates from the hospitalist trainee post‐intervention questionnaire and the residents' questionnaires may affect the validity of our results. For the resident survey, the subjects were not matched, and we cannot state that an individual's geriatric skill practice changed due to PAGE, though the results suggest the residency program as a whole improved the frequency of geriatric skill practice.

Finally, the residents were required to report the frequency of teaching on and practice of geriatric skills practice over the prior year and accuracy of recall may be an issue. However, frequencies were queried both pre and post intervention and favorable change was noted. Furthermore, because the high end of the 3‐point teaching scale was limited to more than once, the true amount of teaching may have been underestimated if more than once actually represented high frequencies.

Future studies are needed to replicate these findings at other institutions to confirm generalizability. It would be beneficial to measure patient outcomes to determine whether increased teaching and skill practice benefits patients using measures such as reduction in catheter related urinary tract infections, falls, and inadequate pain management. Further investigations of cotaught faculty development programs between hospitalists and other specialists help emphasize why internally created TTT programs are of greater value than online resources.

Conclusions

This time‐sensitive adaptation of a hospitalist geriatric TTT program was successfully implemented at an academic medical center and suggests improved hospitalist faculty self‐efficacy at teaching geriatric skills, increased frequency of inpatient geriatric teaching by hospitalists and increased resident geriatric skill practice. Confidence to care for geriatric patients and a strong skill set to assess risks and manage them appropriately will equip hospitalists and trainees to provide care that reduces geriatric patients' in‐hospital morbidity and costs of care. As hospitalists increasingly care for older adults, the need for time‐efficient methods of teaching geriatrics will continue to grow. The PAGE Model, and other new models of geriatric training for hospitalists, demonstrates that we are beginning to address this urgent need.

Wachter and Goldman1 described the hospitalist model for inpatient care more than a decade ago. The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.2 This care delivery model has enjoyed exponential growth, with approximately 20,000 hospitalists in the United States, and an estimated 30,000 by the end of the decade.35 Currently, 29% of hospitals, including 55% with at least 200 beds, employ hospitalists to coordinate inpatient care.6 Data suggests that hospitalists promote cost containment and decrease length of stay without negatively affecting rates of death, readmission, or patient satisfaction.715

In academic settings, hospitalists also provide a substantial amount of teaching to trainees,1618 and the hospitalist model represents a fundamental change in inpatient education delivery. Traditional ward attendings typically consisted of a heterogeneous group of subspecialists, laboratory‐based clinician scientists, and general internists, many of whom attended and taught relatively infrequently. By virtue of focusing purely on inpatient care, hospitalists are more intimately involved with inpatient care systems, as well as teaching challenges (and opportunities) in the inpatient setting. The theoretical educational benefits of hospitalists include greater availability, more expertise in hospital medicine, and more emphasis on cost‐effective care.7, 18, 19 Concerns that trainees would have diminished autonomy and less exposure to subspecialist care have not been borne out.16, 20, 21

The purpose of this study was to examine the role of hospitalists on inpatient trainee education. We systematically reviewed the literature to determine the impact of hospitalists compared to nonhospitalist attendings on medical students' and residents' education.

MATERIALS AND METHODS

RESULTS

Search Results

The database searches yielded 711 articles (Figure 1). Based on review of titles and abstracts, 32 articles were retrieved for full‐text review. During full‐text review, we eliminated 26 studies because they had no nonhospitalist control group,7, 16, 18, 2427 were opinion or review articles,19, 21, 2834 examined hospitalists' roles without trainee outcomes,17, 3540 surveyed program administration,41 or did not involve hospitalists.42, 43 Ultimately, 6 citations published between 2002 and 2007 met all inclusion criteria (Table 1).4449 The updated literature search through October 1, 2008 did not yield any additional relevant studies.

Figure 1

Table 1.Summary of Studies

Location, yearreference	Learners (n)	Number of Attendings	Attending Ward Responsibilities (weeks per year)	Attending Experience (mean years postgraduation)	Attending Gender (% female)	Survey Response Rate (%)	Data Strength
* Meeting abstracts. Brigham & Women's Hospital, University of California San Francisco, University of Chicago, University of Washington, University of Illinois, University of New Mexico. Data strength: 1 (no clear conclusions can be drawn), 2 (results ambiguous, but appears to be a trend), 3 (conclusions can probably be based on results), 4 (results are clear and very likely to be true), 5 (results are unequivocal).
University of Chicago, 200244	PGY‐unspecified (86)	2‐4 hospitalists; unknown nonhospitalists	12‐24 hospitalists; 4‐8 nonhospitalists			58	2
Children's Hospital, Boston, 200245	PGY‐1, PGY‐3 (unknown)	8 hospitalists; 75 nonhospitalists	12‐16 hospitalists; 2‐4 nonhospitalists			63	2
Oregon Health & Sciences, 200446	MS3 (138)	6 hospitalists; 11 nonhospitalists	22.8 hospitalists; 6.4 nonhospitalists	4.2 hospitalists; 10.9 nonhospitalists	2/6 (33%) hospitalists; 4/11 (36%) nonhospitalists	72	3
University of California, San Francisco, 200447	MS3‐4, PGY1‐3 (917)	17 hospitalists; 39 general internists; 13 subspecialists	12 hospitalists; 3.24 nonhospitalists		6/17 (35%) hospitalists; 17/52 (33%) nonhospitalists	91	4
Grady Memorial, 200448	MS3‐4, PGY1‐3 (unknown)	12 hospitalists; 27 general internists; 51 subspecialists	24 hospitalists; 6 nonhospitalists	6.1 hospitalists; 9.7 general internists; 21.6 subspecialists	6/12 (50%) hospitalists; 16/51 (31%) nonhospitalists	81	3
Penn State Children's Hospital, 200749	MS3 (67)	2 hospitalists; 8 nonhospitalists	2 MDs covered 32 hospitalists; 8 MDs covered 28 nonhospitalists		1/2 (50%) hospitalists; 2/8 (25%) nonhospitalists	100	3
Multiple sites, 200550*	MS3 (294)					54	2
California Pacific Medical Center, 200651*	PGY‐unspecified (unknown)						1

Examination of meeting abstracts yielded a total of 7,062 abstracts (Figure 2), of which 9 abstracts were retrieved for full‐text review. Two abstracts met inclusion criteria (Table 1).50, 51 Excluded meeting abstracts included published studies that were already abstracted as manuscripts,52, 53 had no nonhospitalist control group,54, 55 did not involve hospitalists,56 surveyed program administrators,57 or examined hospitalists' roles without trainee outcomes.58 Our communications with abstract authors did not yield any relevant additional information.

Figure 2

DISCUSSION

This systematic review of the literature describing hospitalists as educators shows that trainees are generally more satisfied with hospitalists than nonhospitalists on their inpatient rotations. Hospitalists were rated more highly than traditional ward attendings overall, and for teaching effectiveness44, 47, 49, 50 and feedback delivery.45, 47 Limited data (3 studies each) indicates that trainees perceive hospitalists as being at least as knowledgeable as traditional attendings, and encouraging similar levels of trainee involvement in patient care decisions. Trainees may be more satisfied with hospitalists than with general internists or subspecialists, although some comparisons have shown that general internists may be preferred. No studies have evaluated the impact of hospitalists on trainee outcomes beyond satisfaction, such as knowledge acquisition, rotation grades, or clinical performance.

Our review suggests that, with increased time spent on the wards, hospitalists exhibit attributes consistent with specialization in inpatient care.1, 14 Hospitalists were noted to emphasize cost‐effectiveness47 and evidence‐based medicine48 and to conduct higher‐quality ward rounds.44, 49 Hospitalists are uniquely qualified to teach about inpatient goals and processes such as decreasing length of stay in the hospital and cost‐effective care.1, 3, 7, 12, 15 Trainees see hospitalists as role models,45, 47 and the site‐defined nature of hospital medicine promotes trainees' access to hospitalist attendings. Such accessibility has been described as an independent attribute of excellent physician role models,59, 60, 62 Our findings from our methodologically rigorous systematic review of the literature extend the conclusions of a narrative review of the literature on hospitalists as educators that also identified favorable ratings of hospitalists, with some unresolved concerns about resident autonomy and the role of subspecialist teachers in hospitalist systems.63

Diminished trainee autonomy was an early concern about hospitalists in academic medical centers.16, 20, 21 In the earliest study we identified that assessed autonomy, trainees perceived similar amounts of autonomy with hospitalists compared to nonhospitalists.44 Interestingly, house staff in more experienced hospitalist models even described experiencing increased involvement in patient care when supervised by hospitalist attendings in both the pediatric and internal medicine settings.45, 47 Hospitalists might also generate more clinical diversity for house staff by reducing length of stay and thereby enhancing opportunities for learning with newly admitted patients.13, 14, 64

The studies that did not demonstrate increased satisfaction with hospitalists may be instructive as well. One negative study46 reported results from a program that instituted the hospitalist model in response to declining trainee satisfaction. With an emphasis on improving the educational experience, nonhospitalist physicians who were already rated highly as teachers were also selected to attend on the wards. Nonetheless, trainees still were more satisfied with hospitalists overall. One study showed that hospitalists were rated more highly than subspecialists when delivering feedback but less so than general internists.47 The authors suggest that their general internists may have been at a more optimum demographic by being a few more years out of training; such correlations of age and rank to evaluations have not been previously described.60, 61

The disadvantages of hospitalists in trainee education identified by this systematic review include the quality of bedside teaching in one study45 and interest in psychosocial aspects of care in another48 compared to general internists. The decline in satisfaction with bedside teaching is a concern but the comparison was noncontemporaneous and the authors explained that the team size increased and resulted in an overall decrease in time at the bedside.45 The concern that decreased patient length of stays may translate to less time spent with patients and less bedside teaching is not new.18 Although hospitalists have shown particular educational advantages, the balance of clinical efficiency and education remains challenging. Trainees' perception that hospitalists were less interested in the psychosocial aspects of care compared to general internists48 was also anticipated when inpatient attending models began to shift, because hospitalization may now be viewed by trainees as discontinuous from a patient's outpatient care and social situation.18 Nevertheless, hospitalists have been able to achieve such quality measures as decreased length of stay without decreasing patient satisfaction.10, 12

Our study has several limitations. First, all attendings were rated highly in all studies. These high ratings are commonly seen with educational evaluations,65 and this phenomenon creates a ceiling effect that limits variability within the group. Nevertheless, trainees rated hospitalists significantly higher than nonhospitalists overall in all of the included studies. The impact of these small but significant differences on trainees' learning and future clinical performance is unknown. Additionally, the distinction between hospitalists and nonhospitalists was not universal. Initially, it was proposed that academic hospitalists work as hospitalists 3 to 6 months each year.1 This definition is sustained through almost all included studies that reported attending time on the wards, with hospitalists working 3 to 7 months and nonhospitalists working less than 3 months, but observed variability does not permit a universal hospitalist definition. It is possible that publication bias influenced our findings toward positive ratings of hospitalists; we reviewed and included meeting abstracts to minimize this bias. We did not review family medicine meeting abstracts.

The included studies had some methodologic strengths, including quasirandom assignment of trainees and use of a contemporaneous control group in almost all studies. However, the overall methodologic strength was fair given limitations in response rates and reporting of cointerventions; we thus considered most studies to represent trends rather than definitive results. Finally, all of the studies meeting our inclusion criteria to date only evaluated trainees' attitudes and beliefs. Because knowledge and skills were not objectively assessed, it is unclear how increased trainee satisfaction translates to knowledge and skill acquisition on the wards. However, Miller's pyramid and its proposed modification, the Cambridge model, suggest that targeting attitudes precedes knowledge acquisition,66 and our study suggests the need for a research agenda examining the impact of hospitalists on trainees' future performance. Griffith et al.67 demonstrated an association between increased satisfaction with teaching and medical students' performance on clerkship examinations and the U.S. Medical Licensing Examination (USMLE) Step 2.

Overall, trainees were more satisfied with hospitalists' teaching and feedback delivery. Our literature search shows that, although there are a limited number of studies of varying level of quality that cannot be compared using meta‐analytic techniques, the currently available data suggests that hospitalists lead to improved learner satisfaction. More studies to delineate the differences between hospitalists and nonhospitalist general internists are needed. Continued exploration of the effects of attending age and rank on trainee learning may help determine whether this effect is reproducible, and what facets of attendings' teaching actually impact trainees' knowledge, skill acquisition, and behaviors. Since all studies only evaluated attitudes, studies analyzing knowledge and skills are required to more fully understand the educational outcomes of the hospitalist model.

Wachter and Goldman1 described the hospitalist model for inpatient care more than a decade ago. The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.2 This care delivery model has enjoyed exponential growth, with approximately 20,000 hospitalists in the United States, and an estimated 30,000 by the end of the decade.35 Currently, 29% of hospitals, including 55% with at least 200 beds, employ hospitalists to coordinate inpatient care.6 Data suggests that hospitalists promote cost containment and decrease length of stay without negatively affecting rates of death, readmission, or patient satisfaction.715

In academic settings, hospitalists also provide a substantial amount of teaching to trainees,1618 and the hospitalist model represents a fundamental change in inpatient education delivery. Traditional ward attendings typically consisted of a heterogeneous group of subspecialists, laboratory‐based clinician scientists, and general internists, many of whom attended and taught relatively infrequently. By virtue of focusing purely on inpatient care, hospitalists are more intimately involved with inpatient care systems, as well as teaching challenges (and opportunities) in the inpatient setting. The theoretical educational benefits of hospitalists include greater availability, more expertise in hospital medicine, and more emphasis on cost‐effective care.7, 18, 19 Concerns that trainees would have diminished autonomy and less exposure to subspecialist care have not been borne out.16, 20, 21

The purpose of this study was to examine the role of hospitalists on inpatient trainee education. We systematically reviewed the literature to determine the impact of hospitalists compared to nonhospitalist attendings on medical students' and residents' education.

MATERIALS AND METHODS

RESULTS

Search Results

The database searches yielded 711 articles (Figure 1). Based on review of titles and abstracts, 32 articles were retrieved for full‐text review. During full‐text review, we eliminated 26 studies because they had no nonhospitalist control group,7, 16, 18, 2427 were opinion or review articles,19, 21, 2834 examined hospitalists' roles without trainee outcomes,17, 3540 surveyed program administration,41 or did not involve hospitalists.42, 43 Ultimately, 6 citations published between 2002 and 2007 met all inclusion criteria (Table 1).4449 The updated literature search through October 1, 2008 did not yield any additional relevant studies.

Figure 1

Table 1.Summary of Studies

Location, yearreference	Learners (n)	Number of Attendings	Attending Ward Responsibilities (weeks per year)	Attending Experience (mean years postgraduation)	Attending Gender (% female)	Survey Response Rate (%)	Data Strength
* Meeting abstracts. Brigham & Women's Hospital, University of California San Francisco, University of Chicago, University of Washington, University of Illinois, University of New Mexico. Data strength: 1 (no clear conclusions can be drawn), 2 (results ambiguous, but appears to be a trend), 3 (conclusions can probably be based on results), 4 (results are clear and very likely to be true), 5 (results are unequivocal).
University of Chicago, 200244	PGY‐unspecified (86)	2‐4 hospitalists; unknown nonhospitalists	12‐24 hospitalists; 4‐8 nonhospitalists			58	2
Children's Hospital, Boston, 200245	PGY‐1, PGY‐3 (unknown)	8 hospitalists; 75 nonhospitalists	12‐16 hospitalists; 2‐4 nonhospitalists			63	2
Oregon Health & Sciences, 200446	MS3 (138)	6 hospitalists; 11 nonhospitalists	22.8 hospitalists; 6.4 nonhospitalists	4.2 hospitalists; 10.9 nonhospitalists	2/6 (33%) hospitalists; 4/11 (36%) nonhospitalists	72	3
University of California, San Francisco, 200447	MS3‐4, PGY1‐3 (917)	17 hospitalists; 39 general internists; 13 subspecialists	12 hospitalists; 3.24 nonhospitalists		6/17 (35%) hospitalists; 17/52 (33%) nonhospitalists	91	4
Grady Memorial, 200448	MS3‐4, PGY1‐3 (unknown)	12 hospitalists; 27 general internists; 51 subspecialists	24 hospitalists; 6 nonhospitalists	6.1 hospitalists; 9.7 general internists; 21.6 subspecialists	6/12 (50%) hospitalists; 16/51 (31%) nonhospitalists	81	3
Penn State Children's Hospital, 200749	MS3 (67)	2 hospitalists; 8 nonhospitalists	2 MDs covered 32 hospitalists; 8 MDs covered 28 nonhospitalists		1/2 (50%) hospitalists; 2/8 (25%) nonhospitalists	100	3
Multiple sites, 200550*	MS3 (294)					54	2
California Pacific Medical Center, 200651*	PGY‐unspecified (unknown)						1

Examination of meeting abstracts yielded a total of 7,062 abstracts (Figure 2), of which 9 abstracts were retrieved for full‐text review. Two abstracts met inclusion criteria (Table 1).50, 51 Excluded meeting abstracts included published studies that were already abstracted as manuscripts,52, 53 had no nonhospitalist control group,54, 55 did not involve hospitalists,56 surveyed program administrators,57 or examined hospitalists' roles without trainee outcomes.58 Our communications with abstract authors did not yield any relevant additional information.

Figure 2

DISCUSSION

This systematic review of the literature describing hospitalists as educators shows that trainees are generally more satisfied with hospitalists than nonhospitalists on their inpatient rotations. Hospitalists were rated more highly than traditional ward attendings overall, and for teaching effectiveness44, 47, 49, 50 and feedback delivery.45, 47 Limited data (3 studies each) indicates that trainees perceive hospitalists as being at least as knowledgeable as traditional attendings, and encouraging similar levels of trainee involvement in patient care decisions. Trainees may be more satisfied with hospitalists than with general internists or subspecialists, although some comparisons have shown that general internists may be preferred. No studies have evaluated the impact of hospitalists on trainee outcomes beyond satisfaction, such as knowledge acquisition, rotation grades, or clinical performance.

Our review suggests that, with increased time spent on the wards, hospitalists exhibit attributes consistent with specialization in inpatient care.1, 14 Hospitalists were noted to emphasize cost‐effectiveness47 and evidence‐based medicine48 and to conduct higher‐quality ward rounds.44, 49 Hospitalists are uniquely qualified to teach about inpatient goals and processes such as decreasing length of stay in the hospital and cost‐effective care.1, 3, 7, 12, 15 Trainees see hospitalists as role models,45, 47 and the site‐defined nature of hospital medicine promotes trainees' access to hospitalist attendings. Such accessibility has been described as an independent attribute of excellent physician role models,59, 60, 62 Our findings from our methodologically rigorous systematic review of the literature extend the conclusions of a narrative review of the literature on hospitalists as educators that also identified favorable ratings of hospitalists, with some unresolved concerns about resident autonomy and the role of subspecialist teachers in hospitalist systems.63

Diminished trainee autonomy was an early concern about hospitalists in academic medical centers.16, 20, 21 In the earliest study we identified that assessed autonomy, trainees perceived similar amounts of autonomy with hospitalists compared to nonhospitalists.44 Interestingly, house staff in more experienced hospitalist models even described experiencing increased involvement in patient care when supervised by hospitalist attendings in both the pediatric and internal medicine settings.45, 47 Hospitalists might also generate more clinical diversity for house staff by reducing length of stay and thereby enhancing opportunities for learning with newly admitted patients.13, 14, 64

The studies that did not demonstrate increased satisfaction with hospitalists may be instructive as well. One negative study46 reported results from a program that instituted the hospitalist model in response to declining trainee satisfaction. With an emphasis on improving the educational experience, nonhospitalist physicians who were already rated highly as teachers were also selected to attend on the wards. Nonetheless, trainees still were more satisfied with hospitalists overall. One study showed that hospitalists were rated more highly than subspecialists when delivering feedback but less so than general internists.47 The authors suggest that their general internists may have been at a more optimum demographic by being a few more years out of training; such correlations of age and rank to evaluations have not been previously described.60, 61

The disadvantages of hospitalists in trainee education identified by this systematic review include the quality of bedside teaching in one study45 and interest in psychosocial aspects of care in another48 compared to general internists. The decline in satisfaction with bedside teaching is a concern but the comparison was noncontemporaneous and the authors explained that the team size increased and resulted in an overall decrease in time at the bedside.45 The concern that decreased patient length of stays may translate to less time spent with patients and less bedside teaching is not new.18 Although hospitalists have shown particular educational advantages, the balance of clinical efficiency and education remains challenging. Trainees' perception that hospitalists were less interested in the psychosocial aspects of care compared to general internists48 was also anticipated when inpatient attending models began to shift, because hospitalization may now be viewed by trainees as discontinuous from a patient's outpatient care and social situation.18 Nevertheless, hospitalists have been able to achieve such quality measures as decreased length of stay without decreasing patient satisfaction.10, 12

Our study has several limitations. First, all attendings were rated highly in all studies. These high ratings are commonly seen with educational evaluations,65 and this phenomenon creates a ceiling effect that limits variability within the group. Nevertheless, trainees rated hospitalists significantly higher than nonhospitalists overall in all of the included studies. The impact of these small but significant differences on trainees' learning and future clinical performance is unknown. Additionally, the distinction between hospitalists and nonhospitalists was not universal. Initially, it was proposed that academic hospitalists work as hospitalists 3 to 6 months each year.1 This definition is sustained through almost all included studies that reported attending time on the wards, with hospitalists working 3 to 7 months and nonhospitalists working less than 3 months, but observed variability does not permit a universal hospitalist definition. It is possible that publication bias influenced our findings toward positive ratings of hospitalists; we reviewed and included meeting abstracts to minimize this bias. We did not review family medicine meeting abstracts.

The included studies had some methodologic strengths, including quasirandom assignment of trainees and use of a contemporaneous control group in almost all studies. However, the overall methodologic strength was fair given limitations in response rates and reporting of cointerventions; we thus considered most studies to represent trends rather than definitive results. Finally, all of the studies meeting our inclusion criteria to date only evaluated trainees' attitudes and beliefs. Because knowledge and skills were not objectively assessed, it is unclear how increased trainee satisfaction translates to knowledge and skill acquisition on the wards. However, Miller's pyramid and its proposed modification, the Cambridge model, suggest that targeting attitudes precedes knowledge acquisition,66 and our study suggests the need for a research agenda examining the impact of hospitalists on trainees' future performance. Griffith et al.67 demonstrated an association between increased satisfaction with teaching and medical students' performance on clerkship examinations and the U.S. Medical Licensing Examination (USMLE) Step 2.

Overall, trainees were more satisfied with hospitalists' teaching and feedback delivery. Our literature search shows that, although there are a limited number of studies of varying level of quality that cannot be compared using meta‐analytic techniques, the currently available data suggests that hospitalists lead to improved learner satisfaction. More studies to delineate the differences between hospitalists and nonhospitalist general internists are needed. Continued exploration of the effects of attending age and rank on trainee learning may help determine whether this effect is reproducible, and what facets of attendings' teaching actually impact trainees' knowledge, skill acquisition, and behaviors. Since all studies only evaluated attitudes, studies analyzing knowledge and skills are required to more fully understand the educational outcomes of the hospitalist model.

Wachter and Goldman1 described the hospitalist model for inpatient care more than a decade ago. The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.2 This care delivery model has enjoyed exponential growth, with approximately 20,000 hospitalists in the United States, and an estimated 30,000 by the end of the decade.35 Currently, 29% of hospitals, including 55% with at least 200 beds, employ hospitalists to coordinate inpatient care.6 Data suggests that hospitalists promote cost containment and decrease length of stay without negatively affecting rates of death, readmission, or patient satisfaction.715

In academic settings, hospitalists also provide a substantial amount of teaching to trainees,1618 and the hospitalist model represents a fundamental change in inpatient education delivery. Traditional ward attendings typically consisted of a heterogeneous group of subspecialists, laboratory‐based clinician scientists, and general internists, many of whom attended and taught relatively infrequently. By virtue of focusing purely on inpatient care, hospitalists are more intimately involved with inpatient care systems, as well as teaching challenges (and opportunities) in the inpatient setting. The theoretical educational benefits of hospitalists include greater availability, more expertise in hospital medicine, and more emphasis on cost‐effective care.7, 18, 19 Concerns that trainees would have diminished autonomy and less exposure to subspecialist care have not been borne out.16, 20, 21

The purpose of this study was to examine the role of hospitalists on inpatient trainee education. We systematically reviewed the literature to determine the impact of hospitalists compared to nonhospitalist attendings on medical students' and residents' education.

MATERIALS AND METHODS

RESULTS

Search Results

The database searches yielded 711 articles (Figure 1). Based on review of titles and abstracts, 32 articles were retrieved for full‐text review. During full‐text review, we eliminated 26 studies because they had no nonhospitalist control group,7, 16, 18, 2427 were opinion or review articles,19, 21, 2834 examined hospitalists' roles without trainee outcomes,17, 3540 surveyed program administration,41 or did not involve hospitalists.42, 43 Ultimately, 6 citations published between 2002 and 2007 met all inclusion criteria (Table 1).4449 The updated literature search through October 1, 2008 did not yield any additional relevant studies.

Figure 1

Table 1.Summary of Studies

Location, yearreference	Learners (n)	Number of Attendings	Attending Ward Responsibilities (weeks per year)	Attending Experience (mean years postgraduation)	Attending Gender (% female)	Survey Response Rate (%)	Data Strength
* Meeting abstracts. Brigham & Women's Hospital, University of California San Francisco, University of Chicago, University of Washington, University of Illinois, University of New Mexico. Data strength: 1 (no clear conclusions can be drawn), 2 (results ambiguous, but appears to be a trend), 3 (conclusions can probably be based on results), 4 (results are clear and very likely to be true), 5 (results are unequivocal).
University of Chicago, 200244	PGY‐unspecified (86)	2‐4 hospitalists; unknown nonhospitalists	12‐24 hospitalists; 4‐8 nonhospitalists			58	2
Children's Hospital, Boston, 200245	PGY‐1, PGY‐3 (unknown)	8 hospitalists; 75 nonhospitalists	12‐16 hospitalists; 2‐4 nonhospitalists			63	2
Oregon Health & Sciences, 200446	MS3 (138)	6 hospitalists; 11 nonhospitalists	22.8 hospitalists; 6.4 nonhospitalists	4.2 hospitalists; 10.9 nonhospitalists	2/6 (33%) hospitalists; 4/11 (36%) nonhospitalists	72	3
University of California, San Francisco, 200447	MS3‐4, PGY1‐3 (917)	17 hospitalists; 39 general internists; 13 subspecialists	12 hospitalists; 3.24 nonhospitalists		6/17 (35%) hospitalists; 17/52 (33%) nonhospitalists	91	4
Grady Memorial, 200448	MS3‐4, PGY1‐3 (unknown)	12 hospitalists; 27 general internists; 51 subspecialists	24 hospitalists; 6 nonhospitalists	6.1 hospitalists; 9.7 general internists; 21.6 subspecialists	6/12 (50%) hospitalists; 16/51 (31%) nonhospitalists	81	3
Penn State Children's Hospital, 200749	MS3 (67)	2 hospitalists; 8 nonhospitalists	2 MDs covered 32 hospitalists; 8 MDs covered 28 nonhospitalists		1/2 (50%) hospitalists; 2/8 (25%) nonhospitalists	100	3
Multiple sites, 200550*	MS3 (294)					54	2
California Pacific Medical Center, 200651*	PGY‐unspecified (unknown)						1

Examination of meeting abstracts yielded a total of 7,062 abstracts (Figure 2), of which 9 abstracts were retrieved for full‐text review. Two abstracts met inclusion criteria (Table 1).50, 51 Excluded meeting abstracts included published studies that were already abstracted as manuscripts,52, 53 had no nonhospitalist control group,54, 55 did not involve hospitalists,56 surveyed program administrators,57 or examined hospitalists' roles without trainee outcomes.58 Our communications with abstract authors did not yield any relevant additional information.

Figure 2

DISCUSSION

This systematic review of the literature describing hospitalists as educators shows that trainees are generally more satisfied with hospitalists than nonhospitalists on their inpatient rotations. Hospitalists were rated more highly than traditional ward attendings overall, and for teaching effectiveness44, 47, 49, 50 and feedback delivery.45, 47 Limited data (3 studies each) indicates that trainees perceive hospitalists as being at least as knowledgeable as traditional attendings, and encouraging similar levels of trainee involvement in patient care decisions. Trainees may be more satisfied with hospitalists than with general internists or subspecialists, although some comparisons have shown that general internists may be preferred. No studies have evaluated the impact of hospitalists on trainee outcomes beyond satisfaction, such as knowledge acquisition, rotation grades, or clinical performance.

Our review suggests that, with increased time spent on the wards, hospitalists exhibit attributes consistent with specialization in inpatient care.1, 14 Hospitalists were noted to emphasize cost‐effectiveness47 and evidence‐based medicine48 and to conduct higher‐quality ward rounds.44, 49 Hospitalists are uniquely qualified to teach about inpatient goals and processes such as decreasing length of stay in the hospital and cost‐effective care.1, 3, 7, 12, 15 Trainees see hospitalists as role models,45, 47 and the site‐defined nature of hospital medicine promotes trainees' access to hospitalist attendings. Such accessibility has been described as an independent attribute of excellent physician role models,59, 60, 62 Our findings from our methodologically rigorous systematic review of the literature extend the conclusions of a narrative review of the literature on hospitalists as educators that also identified favorable ratings of hospitalists, with some unresolved concerns about resident autonomy and the role of subspecialist teachers in hospitalist systems.63

Diminished trainee autonomy was an early concern about hospitalists in academic medical centers.16, 20, 21 In the earliest study we identified that assessed autonomy, trainees perceived similar amounts of autonomy with hospitalists compared to nonhospitalists.44 Interestingly, house staff in more experienced hospitalist models even described experiencing increased involvement in patient care when supervised by hospitalist attendings in both the pediatric and internal medicine settings.45, 47 Hospitalists might also generate more clinical diversity for house staff by reducing length of stay and thereby enhancing opportunities for learning with newly admitted patients.13, 14, 64

The studies that did not demonstrate increased satisfaction with hospitalists may be instructive as well. One negative study46 reported results from a program that instituted the hospitalist model in response to declining trainee satisfaction. With an emphasis on improving the educational experience, nonhospitalist physicians who were already rated highly as teachers were also selected to attend on the wards. Nonetheless, trainees still were more satisfied with hospitalists overall. One study showed that hospitalists were rated more highly than subspecialists when delivering feedback but less so than general internists.47 The authors suggest that their general internists may have been at a more optimum demographic by being a few more years out of training; such correlations of age and rank to evaluations have not been previously described.60, 61

The disadvantages of hospitalists in trainee education identified by this systematic review include the quality of bedside teaching in one study45 and interest in psychosocial aspects of care in another48 compared to general internists. The decline in satisfaction with bedside teaching is a concern but the comparison was noncontemporaneous and the authors explained that the team size increased and resulted in an overall decrease in time at the bedside.45 The concern that decreased patient length of stays may translate to less time spent with patients and less bedside teaching is not new.18 Although hospitalists have shown particular educational advantages, the balance of clinical efficiency and education remains challenging. Trainees' perception that hospitalists were less interested in the psychosocial aspects of care compared to general internists48 was also anticipated when inpatient attending models began to shift, because hospitalization may now be viewed by trainees as discontinuous from a patient's outpatient care and social situation.18 Nevertheless, hospitalists have been able to achieve such quality measures as decreased length of stay without decreasing patient satisfaction.10, 12

Our study has several limitations. First, all attendings were rated highly in all studies. These high ratings are commonly seen with educational evaluations,65 and this phenomenon creates a ceiling effect that limits variability within the group. Nevertheless, trainees rated hospitalists significantly higher than nonhospitalists overall in all of the included studies. The impact of these small but significant differences on trainees' learning and future clinical performance is unknown. Additionally, the distinction between hospitalists and nonhospitalists was not universal. Initially, it was proposed that academic hospitalists work as hospitalists 3 to 6 months each year.1 This definition is sustained through almost all included studies that reported attending time on the wards, with hospitalists working 3 to 7 months and nonhospitalists working less than 3 months, but observed variability does not permit a universal hospitalist definition. It is possible that publication bias influenced our findings toward positive ratings of hospitalists; we reviewed and included meeting abstracts to minimize this bias. We did not review family medicine meeting abstracts.

The included studies had some methodologic strengths, including quasirandom assignment of trainees and use of a contemporaneous control group in almost all studies. However, the overall methodologic strength was fair given limitations in response rates and reporting of cointerventions; we thus considered most studies to represent trends rather than definitive results. Finally, all of the studies meeting our inclusion criteria to date only evaluated trainees' attitudes and beliefs. Because knowledge and skills were not objectively assessed, it is unclear how increased trainee satisfaction translates to knowledge and skill acquisition on the wards. However, Miller's pyramid and its proposed modification, the Cambridge model, suggest that targeting attitudes precedes knowledge acquisition,66 and our study suggests the need for a research agenda examining the impact of hospitalists on trainees' future performance. Griffith et al.67 demonstrated an association between increased satisfaction with teaching and medical students' performance on clerkship examinations and the U.S. Medical Licensing Examination (USMLE) Step 2.

Overall, trainees were more satisfied with hospitalists' teaching and feedback delivery. Our literature search shows that, although there are a limited number of studies of varying level of quality that cannot be compared using meta‐analytic techniques, the currently available data suggests that hospitalists lead to improved learner satisfaction. More studies to delineate the differences between hospitalists and nonhospitalist general internists are needed. Continued exploration of the effects of attending age and rank on trainee learning may help determine whether this effect is reproducible, and what facets of attendings' teaching actually impact trainees' knowledge, skill acquisition, and behaviors. Since all studies only evaluated attitudes, studies analyzing knowledge and skills are required to more fully understand the educational outcomes of the hospitalist model.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

Older Americans comprise approximately half the patients on inpatient medical wards. There are too few geriatricians to care for these patients, and few geriatricians practice hospital medicine. Hospitalists often provide the majority of inpatient geriatric care, and at teaching hospitals, hospitalists also play a pivotal role in educating residents and students to provide high‐quality care for hospitalized geriatric patients. Thus, hospitalists will be the primary clinicians educating many trainees to care for older patients, and the hospitalists must be skilled in addressing the clinical syndromes that are common in these patients, including delirium, dementia, falls, and infection.1 Generalists and geriatricians have anticipated a shortfall in clinicians prepared to educate trainees about geriatrics and called for faculty development for generalists in geriatrics.2, 3

In this issue of the Journal of Hospital Medicine, Podrazik and colleagues present initial results from a major initiative to enhance the quality and quantity of geriatric inpatient education for residents and students.4 The Curriculum for the Hospitalized Aging Medical Patient (CHAMP) at the University of Chicago represents a multifaceted faculty development effort funded in part by the Donald W. Reynolds and John A. Hartford Foundations. In 12 half‐day sessions offered weekly, hospitalist and general internist faculty members learned about four thematic areasthe frail older person, hazards of hospitalization, end‐of‐life issues, and transitions of carewhile also receiving training in engaging and effective teaching strategies. At each session, participants drew on their own experiences attending on the wards to generate clinical examples and test new teaching strategies. CHAMP incorporates the attributes of best practices for integrating geriatrics education into internal medicine residency training: it promotes model care for older hospital patients, uses a train‐the‐trainer model, addresses care transitions, and promotes interdisciplinary teamwork.5

CHAMP achieved its initial goals. Faculty participants were satisfied and CHAMP substantially increased participants' confidence in practicing and teaching geriatric care. Faculty participants also gained confidence in their teaching abilities and presumably learned teaching strategies that could be applied to other topics in inpatient medicine. Faculty participants demonstrated modest improvements in their knowledge of geriatric issues and more positive attitudes about geriatrics at the end of the course than at the beginning. It is worth noting that the hospitalist and general internist ward attending physicians who participated in CHAMP were volunteers and may have started the process with greater interest in learning geriatric care than other attendings. Thus, it is unknown whether CHAMP might have greater or lesser effect on other faculty.

The CHAMP train‐the‐trainer model offers the potential to impact future practitioners. Findings of the CHAMP investigators are consistent with the literature on faculty development programs for educators, which shows that faculty development on teaching yields high participant satisfaction, knowledge gains, and improved self‐assessment of the ability to implement changes in teaching practice.6 The use in CHAMP of a diverse menu of teaching strategies and active learning techniques such as case‐based discussions and the Objective Structured Teaching Exercise in a small group of colleagues should promote learning and retention.

Is the CHAMP curriculum worth the cost? The program requires resources to pay for 48 hours for each faculty participant and for instructors with expertise in geriatrics and teaching skills. We estimate that the cost for 12 faculty participants would be roughly $72,000. We believe this investment will likely pay off in terms of enhancing faculty skills, improving faculty job satisfaction, promoting faculty retention in academic or other teaching positions, and improving care provided by trainees. For example, if CHAMP were to lead to the retention and promotion of even 2 faculty for just 1 year, it would save recruitment costs that would exceed the direct program costs, and other benefits of CHAMP would only further add value. However, analysis of the benefits of CHAMP will require more in‐depth evaluation data of its impact. The program leaders currently contact former participants around the time of ward attending to reinforce teaching concepts and encourage implementation of CHAMP materials, through a Commitment to Change contract. The ultimate downstream educational goal would be that these faculty learners retain and apply this newly acquired knowledge and skills in their clinical practice and teaching activities. Ideally, evidence would confirm that these benefits improve patient care. The long‐term evaluation plan for CHAMP incorporates important additional outcome measures including resident and student geriatric knowledge as well as patient satisfaction and clinical outcomes. We commend the authors for aiming to expand their evaluation plan over time and aspiring for sustained changes in teaching practice. The literature on the impact of hospitalists has similarly evolved from early descriptions of hospitalists and the logistics of developing a hospitalist program to sophisticated analyses of the impact of hospitalists on clinical outcomes such as length of stay and mortality.7, 8

The feasibility of disseminating CHAMP is an open question. The University of Chicago model employs a time‐intensive curriculum that engages participants in part by releasing them from clinical duties for a half day per week. Release time was funded through combined support from external funding sources and the Department of Medicine. This model addresses the major barrier to faculty development in geriatrics for general internists: lack of time.2, 9 The investment in intensive, longitudinal faculty development may generate higher returns than periodic short faculty workshop sessions that do not build in the time for role‐playing, practice, and reinforcement of key concepts. This type of intervention may also be more feasible when done in conjunction with one of the approximately 50 Health Resources and Services Administration (HRSA)supported Geriatrics Education Centers, which can fund teachers and infrastructure for faculty development.

How is this article useful for hospitalist educators? Many hospitalists at academic centers serve important teaching functions, and some will aspire to advance their educational efforts through more scholarly activities such as curriculum design. The CHAMP curriculum represents a successful model for hospitalists aiming to follow a rigorous approach to curriculum design relevant to inpatient medicine, and the extensive CHAMP materials are available online.10 It serves as a practical model that could be applied to other clinical topics related to hospital medicine. Hospitalists are effective and respected teachers for residents and students, and they develop unique expertise in the content and process of inpatient medicine.11 The authors followed the 6 steps of effective curriculum design: problem identification, targeted needs assessment, goals and objectives, education methods, implementation, and evaluation.12

The CHAMP curriculum typifies a set of materials that aligns well with the Society of Hospital Medicine (SHM) Core Competencies.13 As part of their needs assessment, the authors also surveyed hospitalists at a regional SHM meeting to determine the geriatrics topics for which they perceived greatest educational need. The Core Competencies chapters on the care of the elderly patient, delirium and dementia, hospital‐acquired infections, and palliative care highlight the common learning goals shared by hospital medicine and geriatrics. Both disciplines also emphasize the team‐based, multidisciplinary approach to care, particularly during care transitions, that is highlighted in the CHAMP curriculum.

More generally, the CHAMP curriculum can be used to teach and assess the Accreditation Council for Graduate Medical Education (ACGME) competencies, which must be assessed in all ACGME‐accredited residency programs.14 In an initial session on Teaching on Today's Wards, CHAMP participants brainstorm about how to incorporate both geriatrics content and the ACGME competencies into their post‐call rounds. The emphasis in CHAMP on the health care system and interdisciplinary care is evident in topics such as end‐of‐life care and transitions in care, and provides opportunity for assessment of residents' performance in the ACGME competency of systems‐based practice. The organization of the curriculum by ACGME competency makes it more applicable today than some prior geriatric curricula that emphasized similar themes but without the emphasis on demonstrating competency as an outcome.15

Hospitalists partnering with the Donald W. Reynolds and John A. Hartford Foundations and other external organizations may find funding opportunities for educational projects. For example, the Hartford Foundation has partnered with SHM since 2002 to support hospitalists' efforts to improve care for older adults. Products of this collaboration include a Geriatric Toolbox that contains assessment tools designed for use with geriatric patients.16 The tools assess a range of parameters including nutritional, functional, and mental status, and the website supplies guidelines on the advantages and disadvantages and appropriate use of each assessment tool. With support from the Hartford Foundation, hospitalists have also conducted several workshops at SHM meetings on improving assessment and care of geriatric patients and developed a discharge‐planning checklist for older adults.

As hospitalist programs gain traction in academic centers, hospitalists will increasingly serve as key geriatric content educators for trainees. The CHAMP curriculum offers a model of intensive faculty development for hospitalists and general internists that clinician educators find engaging and empowering. The partnerships of geriatricians and hospitalists, and of the SHM with national geriatrics organizations, have the potential for widespread benefits for both learners and elderly patients.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.