Shannon K. Martin, MD

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FUTURE: New strategies for hospitalists to overcome challenges in teaching on today's wards

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The implementation of resident duty hour restrictions has created a clinical learning environment on the wards quite different from any previous era. The Accreditation Council for Graduate Medical Education issued its first set of regulations limiting consecutive hours worked for residents in 2003, and further restricted hours in 2011.[1] These restrictions have had many implications across several aspects of patient care, education, and clinical training, particularly for hospitalists who spend the majority of their time in this setting and are heavily involved in undergraduate and graduate clinical education in academic medical centers.[2, 3]

As learning environments have been shifting, so has the composition of learners. The Millennial Generation (or Generation Y), defined as those born approximately between 1980 and 2000, represents those young clinicians currently filling the halls of medical schools and ranks of residency and fellowship programs.[4] Interestingly, the current system of restricted work hours is the only system under which the Millennial Generation has ever trained.

As this new generation represents the bulk of current trainees, hospitalist faculty must consider how their teaching styles can be adapted to accommodate these learners. For teaching hospitalists, an approach that considers the learning environment as affected by duty hours, as well as the preferences of Millennial learners, is necessary to educate the next generation of trainees. This article aimed to introduce potential strategies for hospitalists to better align teaching on the wards with the preferences of Millennial learners under the constraints of residency duty hours.

THE NEWEST GENERATION OF LEARNERS

The Millennial Generation has been well described.[4, 5, 6, 7, 8, 9, 10] Broadly speaking, this generation is thought to have been raised by attentive and involved parents, influencing relationships with educators and mentors; they respect authority but do not hesitate to question the relevance of assignments or decisions. Millennials prefer structured learning environments that focus heavily on interaction and experiential learning, and they value design and appearance in how material is presented.[7] Millennials also seek clear expectations and immediate feedback on their performance, and though they have sometimes been criticized for a strong sense of entitlement, they have a strong desire for collaboration and group‐based activity.[5, 6]

One of the most notable and defining characteristics of the Millennial Generation is an affinity for technology and innovation.[7, 8, 9] Web‐based learning tools that are interactive and engaging, such as blogs, podcasts, or streaming videos are familiar and favored methods of learning. Millennials are skilled at finding information and providing answers and data, but may need help with synthesis and application.[5] They take pride in their ability to multitask, but can be prone to doing so inappropriately, particularly with technology that is readily available.[11]

Few studies have explored characteristics of the Millennial Generation specific to medical trainees. One study examined personality characteristics of Millennial medical students compared to Generation X students (those born from 19651980) at a single institution. Millennial students scored higher on warmth, reasoning, emotional stability, rule consciousness, social boldness, sensitivity, apprehension, openness to change, and perfectionism compared to Generation X students. They scored lower on measures for self‐reliance.[12] Additionally, when motives for behavior were studied, Millennial medical students scored higher on needs for affiliation and achievement, and lower on needs for power.[13]

DUTY HOURS: A GENERATION APART

As noted previously, the Millennial Generation is the first to train exclusively in the era of duty hours restrictions. The oldest members of this generation, those born in 1981, were entering medical school at the time of the first duty hours restrictions in 2003, and thus have always been educated, trained, and practiced in an environment in which work hours were an essential part of residency training.

Though duty hours have been an omnipresent part of training for the Millennial Generation, the clinical learning environment that they have known continues to evolve and change. Time for teaching, in particular, has been especially strained by work hour limits, and this has been noted by both attending physicians and trainees with each iteration of work hours limits. Attendings in one study estimated that time spent teaching on general medicine wards was reduced by about 20% following the 2003 limits, and over 40% of residents in a national survey reported that the 2011 limits had worsened the quality of education.[14, 15]

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

The time limitations imposed by duty hours restrictions have compelled teaching rounds to become more patient‐care centered and often less learner‐centered, as providing patient care becomes the prime obligation for this limited time period. Millennial learners are accustomed to being the center of attention in educational environments, and changing the focus from education to patient care in the wards setting may be an abrupt transition for some learners.[6] However, hospitalists can help restructure teaching opportunities on the clinical wards by using teaching methods of the highest value to Millennial learners to promote learning under the conditions of duty hours limitations.

An approach using these methods was developed by reviewing recent literature as well as educational innovations that have been presented at scholarly meetings (eg, Sal Khan's presentation at the 2012 Association of American Medical Colleges meeting).[16] The authors discussed potential teaching techniques that were thought to be feasible to implement in the context of the current learning environment, with consideration of learning theories that would be most effective for the target group of learners (eg, adult learning theory).[17] A mnemonic was created to consolidate strategies thought to best represent these techniques. FUTURE is a group of teaching strategies that can be used by hospitalists to improve teaching rounds by Flipping the Wards, Using Documentation to Teach, Technology‐Enabled Teaching, Using Guerilla Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments into Rounds.

Flipping the Wards

Millennial learners prefer novel methods of delivery that are interactive and technology based.[7, 8, 9] Lectures and slide‐based presentations frequently do not feature the degree of interactive engagement that they seek, and methods such as case‐based presentations and simulation may be more suitable. The Khan Academy is a not‐for‐profit organization that has been proposed as a model for future directions for medical education.[18] The academy's global classroom houses over 4000 videos and interactive modules to allow students to progress through topics on their own time.[19] Teaching rounds can be similarly flipped such that discussion and group work take place during rounds, whereas lectures, modules, and reading are reserved for individual study.[18]

As time pressures shift the focus of rounds exclusively toward discussion of patient‐care tasks, finding time for teaching outside of rounds can be emphasized to inspire self‐directed learning. When residents need time to tend to immediate patient‐care issues, hospitalist attendings could take the time to search for articles to send to team members. Rather than distributing paper copies that may be lost, cloud‐based data management systems such as Dropbox (Dropbox, San Francisco, CA) or Google Drive (Google Inc., Mountain View, CA) can be used to disseminate articles, which can be pulled up in real time on mobile devices during rounds and later deposited in shared folders accessible to all team members.[20, 21] The advantage of this approach is that it does not require all learners to be present on rounds, which may not be possible with duty hours.

Using Documentation to Teach

Trainees report that one of the most desirable attributes of clinical teachers is when they delineate their clinical reasoning and thought process.[22] Similarly, Millennial learners specifically desire to understand the rationale behind their teachers' actions.[6] Documentation in the medical chart or electronic health record (EHR) can be used to enhance teaching and role‐model clinical reasoning in a transparent and readily available fashion.

Billing requirements necessitate daily attending documentation in the form of an attestation. Hospitalist attendings can use attestations to model thought process and clinical synthesis in the daily assessment of a patient. For example, an attestation one‐liner can be used to concisely summarize the patient's course or highlight the most pressing issue of the day, rather than simply serve as a placeholder for billing or agree with above in reference to housestaff documentation. This practice can demonstrate to residents how to write a short snapshot of a patient's care in addition to improving communication.

Additionally, the EHR can be a useful platform to guide feedback for residents on their clinical performance. Millennial learners prefer specific, immediate feedback, and trainee documentation can serve as a template to show examples of good documentation and clinical reasoning as well as areas needing improvement.[5] These tangible examples of clinical performance are specific and understandable for trainees to guide their self‐learning and improvement.

Technology‐Enabled Teaching

Using technology wisely on the wards can improve efficiency while also taking advantage of teaching methods familiar to Millennial learners. Technology can be used in a positive manner to keep the focus on the patient and enhance teaching when time is limited on rounds. Smartphones and tablets have become an omnipresent part of the clinical environment.[23] Rather than distracting from rounds, these tools can be used to answer clinical questions in real time, thus directly linking the question to the patient's care.

The EHR is a powerful technological resource that is readily available to enhance teaching during a busy ward schedule. Clinical information is electronically accessible at all hours for both trainees and attendings, rather than only at prespecified times on daily rounds, and the Millennial Generation is accustomed to receiving and sharing information in this fashion.[24] Technology platforms that enable simultaneous sharing of information among multiple members of a team can also be used to assist in sharing clinical information in this manner. Health Insurance Portability and Accountability Act‐compliant group text‐messaging applications for smartphones and tablets such as GroupMD (GroupMD, San Francisco, CA) allow members of a team to connect through 1 portal.[25] These discussions can foster communication, inspire clinical questions, and model the practice of timely response to new information.

Using Guerilla Teaching Tactics

Though time may be limited by work hours, there are opportunities embedded into clinical practice to create teaching moments. The principle of guerilla marketing uses unconventional marketing tactics in everyday locales to aggressively promote a product.[26] Similarly, guerilla teaching might be employed on rounds to make teaching points about common patient care issues that occur at nearly every room, such as Foley catheters after seeing one at the beside or hand hygiene after leaving a room. These types of topics are familiar to trainees as well as hospitalist attendings and fulfill the relevance that Millennial learners seek by easily applying them to the patient at hand.

Memory triggers or checklists are another way to systematically introduce guerilla teaching on commonplace topics. The IBCD checklist, for example, has been successfully implemented at our institution to promote adherence to 4 quality measures.[27] IBCD, which stands for immunizations, bedsores, catheters, and deep vein thrombosis prophylaxis, is easily and quickly tacked on as a checklist item at the end of the problem list during a presentation. Similar checklists can serve as teaching points on quality and safety in inpatient care, as well as reminders to consider these issues for every patient.

Rainy Day Teaching

Hospitalist teaching attendings recognize that duty hours have shifted the preferred time for teaching away from busy admission periods such as postcall rounds.[28] The limited time spent reviewing new admissions is now often focused on patient care issues, with much of the discussion eliminated. However, hospitalist attendings can be proactive and save certain teaching moments for rainy day teaching, anticipating topics to introduce during lower census times. Additionally, attending access to the EHRs allows attendings to preview cases the residents have admitted during a call period and may facilitate planning teaching topics for future opportunities.[23]

Though teaching is an essential part of the hospitalist teaching attending role, the Millennial Generation's affinity for teamwork makes it possible to utilize additional team members as teachers for the group. This type of distribution of responsibility, or outsourcing of teaching, can be done in the form of a teaching or float resident. These individuals can be directed to search the literature to answer clinical questions the team may have during rounds and report back, which may influence decision making and patient care as well as provide education.[29]

Embedding Teaching Moments Into Rounds

Dr. Francis W. Peabody may have been addressing students many generations removed from Millennial learners when he implored them to remember that the secret of the care of the patient is in caring for the patient, but his maxim still rings true today.[30] This advice provides an important insight on how the focus can be kept on the patient by emphasizing physical examination and history‐taking skills, which engages learners in hands‐on activity and grounds that education in a patient‐based experience.[31] The Stanford 25 represents a successful project that refocuses the doctorpatient encounter on the bedside.[32] Using a Web‐based platform, this initiative instructs on 25 physical examination maneuvers, utilizing teaching methods that are familiar to Millennial learners and are patient focused.

In addition to emphasizing bedside teaching, smaller moments can be used during rounds to establish an expectation for learning. Hospitalist attendings can create a routine with daily teaching moments, such as an electrocardiogram or a daily Medical Knowledge Self‐Assessment Program question, a source of internal medicine board preparation material published by the American College of Physicians.[33] These are opportunities to inject a quick educational moment that is easily relatable to the patients on the team's service. Using teaching moments that are routine, accessible, and relevant to patient care can help shape Millennial learners' expectations that teaching be a daily occurrence interwoven within clinical care provided during rounds.

There are several limitations to our work. These strategies do not represent a systematic review, and there is little evidence to support that our approach is more effective than conventional teaching methods. Though we address hospitalists specifically, these strategies are likely suitable for all inpatient educators as they have not been well studied in specific groups. With the paucity of literature regarding learning preferences of Millennial medical trainees, it is difficult to know what methods may truly be most desirable in the wards setting, as many of the needs and learning styles considered in our approach are borrowed from other more traditional learning environments. It is unclear how adoptable our strategies may be for educators from other generations; these faculty may have different approaches to teaching. Further research is necessary to identify areas for faculty development in learning new techniques as well as compare the efficacy of our approach to conventional methods with respect to standardized educational outcomes such as In‐Training Exam performance, as well as patient outcomes.

ACCEPTING THE CHALLENGE

The landscape of clinical teaching has shifted considerably in recent years, in both the makeup of learners for whom educators are responsible for teaching as well as the challenges in teaching under the duty hours restrictions. Though rounds are more focused on patient care than in the past, it is possible to work within the current structure to promote successful learning with an approach that considers the preferences of today's learners.

A hospitalist's natural habitat, the busy inpatient wards, is a clinical learning environment with rich potential for innovation and excellence in teaching. The challenges in practicing hospital medicine closely parallel the challenges in teaching under the constraints of duty hours restrictions; both require a creative approach to problem solving and an affinity for teamwork. The hospitalist community is well suited to not only meet these challenges but become leaders in embracing how to teach effectively on today's wards. Maximizing interaction, embracing technology, and encouraging group‐based learning may represent the keys to a successful approach to teaching the Millennial Generation in a post‐duty hours world.

Disclosures: All coauthors have seen and agree with the contents of the article. The submission is not under review by any other publication. Dr. Arora discloses financial support in the form of grants received from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education prior to this work. The other authors have no financial conflicts of interest to disclose.

Table 1.Hospitalist Teaching Rounds for the FUTURE
FUTURE		Definition	Example Strategies
NOTE: Abbreviations: ECG, electrocardiogram; HIPAA, Health Insurance Portability and Accountability Act; MKSAP, Medical Knowledge Self Assessment Program; SMS, short‐message system.
F	Flipping the Wards	Lectures, readings, and modules as materials for self‐study and homework to encourage use of group time for interactive discussion	Emailing an article after rounds to review and discuss the next day
F	Flipping the Wards		Cloud‐sharing landmark articles (eg, Dropbox)
Messaging and chat platforms for discussion
U	Using Documentation to Teach	Using the chart as a platform for education and role‐modeling in clinical documentation	Documenting your thought process in attending attestations/notes
U	Using Documentation to Teach		Using attending attestation to provide feedback on documentation and communication
T	Technology‐Enabled Teaching	Technological devices and applications to augment bedside teaching and interactive discussions	Using apps on smartphones and tablet devices to highlight teaching points (eg, use of prognostic calculators)
T	Technology‐Enabled Teaching		HIPAA‐compliant SMS text‐messaging or group chats to discuss patient updates and rationales for management
U	Using Guerilla Teaching Tactics	Exploiting the natural learning environment to facilitate teaching points	Teaching what is seen on rounds routinely (eg, census audit to remove Foley catheters, hand hygiene, indications for contact isolation, medication reconciliation)
U	Using Guerilla Teaching Tactics		Checklists and quality measures incorporated into every presentation
R	Rainy Day Teaching	Saving important teaching points for a rainy day when there is more time for teaching	Noting teaching points from postcall or busy admission times to revisit during a less busy day
R	Rainy Day Teaching		Appointing certain team members as teaching residents to outsource clinical questions and bring back to the group
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Bringing focus of rounds back to bedside teaching and physical examination (eg, Stanford 25)
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Daily expected teaching moments, (eg, ECG or MKSAP question of the day)

Files

References

Nasca TJ, Day SH, Amis ES; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
Liston BW, O'Dorisio N, Walker C, et al. Hospital medicine in the internal medicine clerkship: results from a national survey. J Hosp Med. 2012;7(7):557–561.
Howe N, Strauss W. Millennials Rising: The Next Great Generation. New York, NY: Random House/Vintage Books; 2000.
Eckleberry‐Hunt J, Tucciarone J. The challenges and opportunities of teaching “Generation Y.” J Grad Med Educ.2011;3(4):458–461.
Twenge JM. Generational changes and their impact in the classroom: teaching Generation Me. Med Educ. 2009;43(5):398–405.
Roberts DH, Newman LR, Schwarzstein RM. Twelve tips for facilitating Millennials' learning. Med Teach. 2012;34(4):274–278.
Pew Research Center. Millennials: a portrait of generation next. Available at: http://pewsocialtrends.org/files/2010/10/millennials‐confident‐connected‐open‐to‐change.pdf. Accessed February 28, 2013.
Mohr NM, Moreno‐Walton L, Mills AM, et al. Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part I). Acad Emerg Med. 2011;18(2):190–199.
Mohr NM, Moreno‐Walton L, Mills AM, et al. Generational influences in academic emergency medicine: structure, function, and culture (part II). Acad Emerg Med. 2011;18(2):200–207.
Katz‐Sidlow RJ, Ludwig A, Miller S, Sidlow R. Smartphone use during inpatient attending rounds: prevalence, patterns, and potential for distraction. J Hosp Med. 2012;8:595–599.
Borges NJ, Manuel RS, Elam CL, et al. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006;81(6):571–576.
Borges NJ, Manuel RS, Elam CL, Jones BJ. Differences in motives between Millennial and Generation X students. Med Educ. 2010;44(6):570–576.
Arora V, Meltzer D. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226–1227.
Drolet BC, Christopher DA, Fischer SA. Residents' response to duty‐hours regulations—a follow‐up national survey. N Engl J Med. 2012; 366(24):e35.
Khan S. Innovation arc: new approaches. Presented at: Association of American Colleges of Medicine National Meeting; November 2012; San Francisco, CA.
Spencer JA, Jordan RK. Learner‐centered approaches in medical education. BMJ. 1999;318:1280–1283.
Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366(18):1657–1659.
The Khan Academy. Available at: https://www.khanacademy.org/. Accessed March 4, 2013.
Dropbox. Dropbox Inc. Available at: https://www.dropbox.com/. Accessed April 19, 2013.
Google Drive. Google Inc. Available at: https://drive.google.com/. Accessed April 19, 2013.
Sutkin G, Wagner E, Harris I, et al. What makes a good clinical teacher in medicine? A review of the literature. Acad Med. 2008;83(5):452–466.
Baumgart DC. Smartphones in clinical practice, medical education, and research. Arch Intern Med. 2011;171(14):1294–1296.
Martin SK, Tulla K, Meltzer DO, et al. Attending use of the electronic health record (EHR) and implications for housestaff supervision. Presented at: Midwest Society of General Internal Medicine Regional Meeting; September 2012; Chicago, IL.
GroupMD. GroupMD Inc. Available at http://group.md. Accessed April 19, 2013.
Levinson J. Guerilla Marketing: Secrets for Making Big Profits From Your Small Business. Boston, MA: Houghton Mifflin; 1984.
Aspesi A, Kauffmann GE, Davis AM, et al. IBCD: development and testing of a checklist to improve quality of care for hospitalized general medical patients. Jt Comm J Qual Patient Saf. 2013;39(4):147–156.
Cohen S, Sarkar U. Ice cream rounds. Acad Med. 2013;88(1):66.
Lucas BP, Evans AT, Reilly BM, et al. The impact of evidence on physicians' inpatient treatment decisions. J Gen Intern Med. 2004; 19(5 pt 1):402–409.
Peabody FW. Landmark article March 19, 1927: the care of the patient. By Francis W. Peabody. JAMA. 1984;252(6):813–818.
Gonzalo JD, Heist BS, Duffy BL, et al. The art of bedside rounds: a multi‐center qualitative study of strategies used by experienced bedside teachers. J Gen Intern Med. 2013;28(3):412–420.
Stanford University School of Medicine. Stanford Medicine 25. Available at: http://stanfordmedicine25.stanford.edu/. Accessed February 28, 2013.
Medical Knowledge Self‐Assessment Program 16. The American College of Physicians. Available at: https://mksap.acponline.org. Accessed April 19, 2013.

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THE NEWEST GENERATION OF LEARNERS

DUTY HOURS: A GENERATION APART

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

Flipping the Wards

Using Documentation to Teach

Technology‐Enabled Teaching

Using Guerilla Teaching Tactics

Rainy Day Teaching

Embedding Teaching Moments Into Rounds

ACCEPTING THE CHALLENGE

Table 1.Hospitalist Teaching Rounds for the FUTURE
FUTURE		Definition	Example Strategies
NOTE: Abbreviations: ECG, electrocardiogram; HIPAA, Health Insurance Portability and Accountability Act; MKSAP, Medical Knowledge Self Assessment Program; SMS, short‐message system.
F	Flipping the Wards	Lectures, readings, and modules as materials for self‐study and homework to encourage use of group time for interactive discussion	Emailing an article after rounds to review and discuss the next day
F	Flipping the Wards		Cloud‐sharing landmark articles (eg, Dropbox)
Messaging and chat platforms for discussion
U	Using Documentation to Teach	Using the chart as a platform for education and role‐modeling in clinical documentation	Documenting your thought process in attending attestations/notes
U	Using Documentation to Teach		Using attending attestation to provide feedback on documentation and communication
T	Technology‐Enabled Teaching	Technological devices and applications to augment bedside teaching and interactive discussions	Using apps on smartphones and tablet devices to highlight teaching points (eg, use of prognostic calculators)
T	Technology‐Enabled Teaching		HIPAA‐compliant SMS text‐messaging or group chats to discuss patient updates and rationales for management
U	Using Guerilla Teaching Tactics	Exploiting the natural learning environment to facilitate teaching points	Teaching what is seen on rounds routinely (eg, census audit to remove Foley catheters, hand hygiene, indications for contact isolation, medication reconciliation)
U	Using Guerilla Teaching Tactics		Checklists and quality measures incorporated into every presentation
R	Rainy Day Teaching	Saving important teaching points for a rainy day when there is more time for teaching	Noting teaching points from postcall or busy admission times to revisit during a less busy day
R	Rainy Day Teaching		Appointing certain team members as teaching residents to outsource clinical questions and bring back to the group
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Bringing focus of rounds back to bedside teaching and physical examination (eg, Stanford 25)
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Daily expected teaching moments, (eg, ECG or MKSAP question of the day)

THE NEWEST GENERATION OF LEARNERS

DUTY HOURS: A GENERATION APART

GENERATIONAL STRATEGIES FOR SUCCESS FOR HOSPITALIST TEACHING ATTENDINGS

Flipping the Wards

Using Documentation to Teach

Technology‐Enabled Teaching

Using Guerilla Teaching Tactics

Rainy Day Teaching

Embedding Teaching Moments Into Rounds

ACCEPTING THE CHALLENGE

Table 1.Hospitalist Teaching Rounds for the FUTURE
FUTURE		Definition	Example Strategies
NOTE: Abbreviations: ECG, electrocardiogram; HIPAA, Health Insurance Portability and Accountability Act; MKSAP, Medical Knowledge Self Assessment Program; SMS, short‐message system.
F	Flipping the Wards	Lectures, readings, and modules as materials for self‐study and homework to encourage use of group time for interactive discussion	Emailing an article after rounds to review and discuss the next day
F	Flipping the Wards		Cloud‐sharing landmark articles (eg, Dropbox)
Messaging and chat platforms for discussion
U	Using Documentation to Teach	Using the chart as a platform for education and role‐modeling in clinical documentation	Documenting your thought process in attending attestations/notes
U	Using Documentation to Teach		Using attending attestation to provide feedback on documentation and communication
T	Technology‐Enabled Teaching	Technological devices and applications to augment bedside teaching and interactive discussions	Using apps on smartphones and tablet devices to highlight teaching points (eg, use of prognostic calculators)
T	Technology‐Enabled Teaching		HIPAA‐compliant SMS text‐messaging or group chats to discuss patient updates and rationales for management
U	Using Guerilla Teaching Tactics	Exploiting the natural learning environment to facilitate teaching points	Teaching what is seen on rounds routinely (eg, census audit to remove Foley catheters, hand hygiene, indications for contact isolation, medication reconciliation)
U	Using Guerilla Teaching Tactics		Checklists and quality measures incorporated into every presentation
R	Rainy Day Teaching	Saving important teaching points for a rainy day when there is more time for teaching	Noting teaching points from postcall or busy admission times to revisit during a less busy day
R	Rainy Day Teaching		Appointing certain team members as teaching residents to outsource clinical questions and bring back to the group
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Bringing focus of rounds back to bedside teaching and physical examination (eg, Stanford 25)
E	Embedding Teaching Moments into Rounds	Routinizing an expected teaching moment into rounds	Daily expected teaching moments, (eg, ECG or MKSAP question of the day)

References

Nasca TJ, Day SH, Amis ES; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
Liston BW, O'Dorisio N, Walker C, et al. Hospital medicine in the internal medicine clerkship: results from a national survey. J Hosp Med. 2012;7(7):557–561.
Howe N, Strauss W. Millennials Rising: The Next Great Generation. New York, NY: Random House/Vintage Books; 2000.
Eckleberry‐Hunt J, Tucciarone J. The challenges and opportunities of teaching “Generation Y.” J Grad Med Educ.2011;3(4):458–461.
Twenge JM. Generational changes and their impact in the classroom: teaching Generation Me. Med Educ. 2009;43(5):398–405.
Roberts DH, Newman LR, Schwarzstein RM. Twelve tips for facilitating Millennials' learning. Med Teach. 2012;34(4):274–278.
Pew Research Center. Millennials: a portrait of generation next. Available at: http://pewsocialtrends.org/files/2010/10/millennials‐confident‐connected‐open‐to‐change.pdf. Accessed February 28, 2013.
Mohr NM, Moreno‐Walton L, Mills AM, et al. Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part I). Acad Emerg Med. 2011;18(2):190–199.
Mohr NM, Moreno‐Walton L, Mills AM, et al. Generational influences in academic emergency medicine: structure, function, and culture (part II). Acad Emerg Med. 2011;18(2):200–207.
Katz‐Sidlow RJ, Ludwig A, Miller S, Sidlow R. Smartphone use during inpatient attending rounds: prevalence, patterns, and potential for distraction. J Hosp Med. 2012;8:595–599.
Borges NJ, Manuel RS, Elam CL, et al. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006;81(6):571–576.
Borges NJ, Manuel RS, Elam CL, Jones BJ. Differences in motives between Millennial and Generation X students. Med Educ. 2010;44(6):570–576.
Arora V, Meltzer D. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226–1227.
Drolet BC, Christopher DA, Fischer SA. Residents' response to duty‐hours regulations—a follow‐up national survey. N Engl J Med. 2012; 366(24):e35.
Khan S. Innovation arc: new approaches. Presented at: Association of American Colleges of Medicine National Meeting; November 2012; San Francisco, CA.
Spencer JA, Jordan RK. Learner‐centered approaches in medical education. BMJ. 1999;318:1280–1283.
Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366(18):1657–1659.
The Khan Academy. Available at: https://www.khanacademy.org/. Accessed March 4, 2013.
Dropbox. Dropbox Inc. Available at: https://www.dropbox.com/. Accessed April 19, 2013.
Google Drive. Google Inc. Available at: https://drive.google.com/. Accessed April 19, 2013.
Sutkin G, Wagner E, Harris I, et al. What makes a good clinical teacher in medicine? A review of the literature. Acad Med. 2008;83(5):452–466.
Baumgart DC. Smartphones in clinical practice, medical education, and research. Arch Intern Med. 2011;171(14):1294–1296.
Martin SK, Tulla K, Meltzer DO, et al. Attending use of the electronic health record (EHR) and implications for housestaff supervision. Presented at: Midwest Society of General Internal Medicine Regional Meeting; September 2012; Chicago, IL.
GroupMD. GroupMD Inc. Available at http://group.md. Accessed April 19, 2013.
Levinson J. Guerilla Marketing: Secrets for Making Big Profits From Your Small Business. Boston, MA: Houghton Mifflin; 1984.
Aspesi A, Kauffmann GE, Davis AM, et al. IBCD: development and testing of a checklist to improve quality of care for hospitalized general medical patients. Jt Comm J Qual Patient Saf. 2013;39(4):147–156.
Cohen S, Sarkar U. Ice cream rounds. Acad Med. 2013;88(1):66.
Lucas BP, Evans AT, Reilly BM, et al. The impact of evidence on physicians' inpatient treatment decisions. J Gen Intern Med. 2004; 19(5 pt 1):402–409.
Peabody FW. Landmark article March 19, 1927: the care of the patient. By Francis W. Peabody. JAMA. 1984;252(6):813–818.
Gonzalo JD, Heist BS, Duffy BL, et al. The art of bedside rounds: a multi‐center qualitative study of strategies used by experienced bedside teachers. J Gen Intern Med. 2013;28(3):412–420.
Stanford University School of Medicine. Stanford Medicine 25. Available at: http://stanfordmedicine25.stanford.edu/. Accessed February 28, 2013.
Medical Knowledge Self‐Assessment Program 16. The American College of Physicians. Available at: https://mksap.acponline.org. Accessed April 19, 2013.

References

Nasca TJ, Day SH, Amis ES; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
Liston BW, O'Dorisio N, Walker C, et al. Hospital medicine in the internal medicine clerkship: results from a national survey. J Hosp Med. 2012;7(7):557–561.
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FUTURE: New strategies for hospitalists to overcome challenges in teaching on today's wards

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Address for correspondence and reprint requests: Shannon Martin, MD, 5841 S. Maryland Avenue MC 5000, W307, Chicago, IL 60637; Telephone: 773‐702‐2604; Fax: 773–795‐7398; E‐mail: [email protected]

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Attendings' Perception of Housestaff

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How do attendings perceive housestaff autonomy? Attending experience, hospitalists, and trends over time

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David O. Meltzer, MD, PhD

Ainoa Mayo, MA

Benjamin Vekhter, PhD

Clinical supervision in graduate medical education (GME) emphasizes patient safety while promoting development of clinical expertise by allowing trainees progressive independence.[1, 2, 3] The importance of the balance between supervision and autonomy has been recognized by accreditation organizations, namely the Institute of Medicine and the Accreditation Council for Graduate Medical Education (ACGME).[4, 5] However, little is known of best practices in supervision, and the model of progressive independence in clinical training lacks empirical support.[3] Limited evidence suggests that enhanced clinical supervision may have positive effects on patient and education‐related outcomes.[6, 7, 8, 9, 10, 11, 12, 13, 14, 15] However, a more nuanced understanding of potential effects of enhanced supervision on resident autonomy and decision making is still required, particularly as preliminary work on increased on‐site hospitalist supervision has yielded mixed results.[16, 17, 18, 19]

Understanding how trainees are entrusted with autonomy will be integral to the ACGME's Next Accreditation System.[20] Entrustable Professional Activities are benchmarks by which resident readiness to progress through training will be judged.[21] The extent to which trainees are entrusted with autonomy is largely determined by the subjective assessment of immediate supervisors, as autonomy is rarely measured or quantified.[3, 22, 23] This judgment of autonomy, most frequently performed by ward attendings, may be subject to significant variation and influenced by factors other than the resident's competence and clinical abilities.

To that end, it is worth considering what factors may affect attending perception of housestaff autonomy and decision making. Recent changes in the GME environment and policy implementation have altered the landscape of the attending workforce considerably. The growth of the hospitalist movement in teaching hospitals, in part due to duty hours, has led to more residents being supervised by hospitalists, who may perceive trainee autonomy differently than other attendings do.[24] This study aims to examine whether factors such as attending demographics and short‐term and long‐term secular trends influence attending perception of housestaff autonomy and participation in decision making.

METHODS

Study Design

From 2001 to 2008, attending physicians at a single academic institution were surveyed at the end of inpatient general medicine teaching rotations.[25] The University of Chicago general medicine service consists of ward teams of an attending physician (internists, hospitalists, or subspecialists), 1 senior resident, and 1 or 2 interns. Attendings serve for 2‐ or 4‐week rotations. Attendings were consented for participation and received a 40‐item, paper‐based survey at the rotation's end. The institutional review board approved this study.

Data Collection

From the 40 survey items, 2 statements were selected for analysis: The intern(s) were truly involved in decision making about their patients and My resident felt that s/he had sufficient autonomy this month. These items have been used in previous work studying attending‐resident dynamics.[19, 26] Attendings also reported demographic and professional information as well as self‐identified hospitalist status, ascertained by the question Do you consider yourself to be a hospitalist? Survey month and year were also recorded. We conducted a secondary data analysis of an inclusive sample of responses to the questions of interest.

Statistical Analysis

Descriptive statistics were used to summarize survey responses and demographics. Survey questions consisted of Likert‐type items. Because the distribution of responses was skewed toward strong agreement for both questions, we collapsed scores into 2 categories (Strongly Agree and Do Not Strongly Agree).[19] Perception of sufficient trainee autonomy was defined as a response of Strongly Agree. The Pearson ² test was used to compare proportions, and t tests were used to compare mean years since completion of residency and weeks on service between different groups.

Multivariate logistic regression with stepwise forward regression was used to model the relationship between attending sex, institutional hospitalist designation, years of experience, implementation of duty‐hours restrictions, and academic season, and perception of trainee autonomy and decision making. Academic seasons were defined as summer (JulySeptember), fall (OctoberDecember), winter (JanuaryMarch) and spring (AprilJune).[26] Years of experience were divided into tertiles of years since residency: 04 years, 511 years, and >11 years. To account for the possibility that the effect of hospitalist specialty varied by experience, interaction terms were constructed. The interaction term hospitalist*early‐career was used as the reference group.

RESULTS

Seven hundred thirty‐eight surveys were distributed to attendings on inpatient general medicine teaching services from 2001 to 2008; 70% (n=514) were included in the analysis. Table 1 provides demographic characteristics of the respondents. Roughly half (47%) were female, and 23% were hospitalists. Experience ranged from 0 to 35 years, with a median of 7 years. Weeks on service per year ranged from 1 to 27, with a median of 6 weeks. Hospitalists represented a less‐experienced group of attendings, as their mean experience was 4.5 years (standard deviation [SD] 4.5) compared with 11.2 years (SD 7.7) for nonhospitalists (P<0.001). Hospitalists attended more frequently, with a mean 14.2 weeks on service (SD 6.5) compared with 5.8 weeks (SD 3.4) for nonhospitalists (P<0.001). Nineteen percent (n=98) of surveys were completed prior to the first ACGME duty‐hours restriction in 2003. Responses were distributed fairly equally across the academic year, with 29% completed in summer, 26% in fall, 24% in winter, and 21% in spring.

Table 1.Attending Physician Demographic Characteristics
Characteristics	Value
NOTE: Abbreviations: IQR, interquartile range; SD, standard deviation. a Because of missing data, numbers may not correspond to exact percentages. b Data only available beyond academic year 20032004.
Female, n (%)	275 (47)
Hospitalist, n (%)	125 (23)
Years since completion of residency
Mean, median, SD	9.3, 7, 7.6
IQR	314
04, n (%)	167 (36)
511, n (%)	146 (32)
>11, n (%)	149 (32)
Weeks on service per yearb
Mean, median, SD	8.1, 6, 5.8
IQR	412

Forty‐four percent (n=212) of attendings perceived adequate intern involvement in decision making, and 50% (n=238) perceived sufficient resident autonomy. The correlation coefficient between these 2 measures was 0.66.

Attending Factors Associated With Perception of Trainee Autonomy

In univariate analysis, hospitalists perceived sufficient trainee autonomy less frequently than nonhospitalists; 33% perceived adequate intern involvement in decision making compared with 48% of nonhospitalists (²₁=6.7, P=0.01), and 42% perceived sufficient resident autonomy compared with 54% of nonhospitalists (²₁=3.9, P=0.048) (Table 2).

Table 2.Attending Characteristics and Time Trends Associated With Perception of Intern Involvement in Decision Making and Resident Autonomy
Attending Characteristics, n (%)	Agree With Intern Involvement in Decision Making	Agree With Sufficient Resident Autonomy
NOTE: Abbreviations: F, female; M, male. a Because of missing data, numbers may not correspond to exact percentages.
Designation
Hospitalist	29 (33)	37 (42)
Nonhospitalist	163 (48)	180 (54)
Years since completion of residency
04	37 (27)	49 (36)
511	77 (53)	88 (61)
>11	77 (53)	81 (56)
Sex
F	98 (46)	100 (47)
M	113 (43)	138 (53)
Secular factors, n (%)
Pre‐2003 duty‐hours restrictions	56 (57)	62 (65)
Post‐2003 duty‐hours restrictions	156 (41)	176 (46)
Season of survey
Summer (JulySeptember)	61 (45)	69 (51)
Fall (OctoberDecember)	53 (42)	59 (48)
Winter (JanuaryMarch)	42 (37)	52 (46)
Spring (AprilJune)	56 (54)	58 (57)

Perception of trainee autonomy increased with experience (Table 2). About 30% of early‐career attendings (04 years experience) perceived sufficient autonomy and involvement in decision making compared with >50% agreement in the later‐career tertiles (intern decision making: ²₂=25.1, P<0.001; resident autonomy: ²₂=18.9, P<0.001). Attendings perceiving more intern decision making involvement had a mean 11 years of experience (SD 7.1), whereas those perceiving less had a mean of 8.8 years (SD 7.8; P=0.003). Mean years of experience were similar for perception of resident autonomy (10.6 years [SD 7.2] vs 8.9 years [SD 7.8], P=0.021).

Sex was not associated with differences in perception of intern decision making (²₁=0.39, P=0.53) or resident autonomy (²₁=1.4, P=0.236) (Table 2).

Secular Factors Associated With Perception of Trainee Autonomy

The implementation of duty‐hour restrictions in 2003 was associated with decreased attending perception of autonomy. Only 41% of attendings perceived adequate intern involvement in decision making following the restrictions, compared with 57% before the restrictions were instituted (²₁=8.2, P=0.004). Similarly, 46% of attendings agreed with sufficient resident autonomy post‐duty hours, compared with 65% prior (²₁=10.1, P=0.001) (Table 2).

Academic season was also associated with differences in perception of autonomy (Table 2). In spring, 54% of attendings perceived adequate intern involvement in decision making, compared with 42% in the other seasons combined (²₁=5.34, P=0.021). Perception of resident autonomy was also higher in spring, though this was not statistically significant (57% in spring vs 48% in the other seasons; ²₁=2.37, P=0.123).

Multivariate Analyses

Variation in attending perception of housestaff autonomy by attending characteristics persisted in multivariate analysis. Table 3 shows ORs for perception of adequate intern involvement in decision making and sufficient resident autonomy. Sex was not a significant predictor of agreement with either statement. The odds that an attending would perceive adequate intern involvement in decision making were higher for later‐career attendings compared with early‐career attendings (ie, 04 years); attendings who completed residency 511 years ago were 2.16 more likely to perceive adequate involvement (OR: 2.16, 95% CI: 1.17‐3.97, P=0.013), and those >11 years from residency were 2.05 more likely (OR: 2.05, 95% CI: 1.16‐3.63, P=0.014). Later‐career attendings also had nonsignificant higher odds of perceiving sufficient resident autonomy compared with early‐career attendings (511 years, OR: 1.73, 95% CI: 0.963.14, P=0.07; >11 years, OR: 1.50, 95% CI: 0.862.62, P=0.154).

Table 3.Association Between Agreement With Housestaff Autonomy and Attending Characteristics and Secular Factors
	Interns Involved With Decision Making		Resident Had Sufficient Autonomy
NOTE: Abbreviations: CI, confidence interval; OR, odds ratio. a Multivariate logistic regression model to determine association between sex, years of experience, hospitalist specialty, duty hours, academic season, and the interaction between hospitalist specialty and experience with attending physician agreement with intern involvement in decision making. Similarly, the second model was to determine the association between the above‐listed factors and attending agreement with sufficient resident autonomy. Male sex was used as the reference group in the analysis. Experience was divided into tertiles of years since completion of residency: first tertile (04 years), second tertile (511 years) and third tertile (>11 years). First tertile of years of experience was used as the reference group in the analysis. Similarly, hospitalist*04 years of experience was the reference group when determining the effects of the interaction between hospitalist specialty and experience. The duty‐hours covariate is the responses after implementation of the 2003 duty‐hours restriction. Academic year was studied as spring season (MarchJune) compared with the other seasons.
Covariate	OR (95% CI)	P Value	OR (95% CI)	P Value
Attending characteristics
04 years of experience
511 years of experience	2.16 (1.17‐3.97)	0.013	1.73 (0.96‐3.14)	0.07
>11 years of experience	2.05 (1.16‐3.63)	0.014	1.50 (0.86‐2.62)	0.154
Hospitalist	0.19 (0.06‐0.58)	0.004	0.27 (0.11‐0.66)	0.004
Hospitalist 04 years of experiencea
Hospitalist 511 years of experiencea	7.36 (1.86‐29.1)	0.004	5.85 (1.75‐19.6)	0.004
Hospitalist >11 years of experiencea	21.2 (1.73‐260)	0.017	14.4 (1.31‐159)	0.029
Female sex	1.41 (0.92‐2.17)	0.115	0.92 (0.60‐1.40)	0.69
Secular factors
Post‐2003 duty hours	0.51 (0.29‐0.87)	0.014	0.49 (0.28‐0.86)	0.012
Spring academic season	1.94 (1.18‐3.19)	0.009	1.59 (0.97‐2.60)	0.064

Hospitalists were associated with 81% lower odds of perceiving adequate intern involvement in decision making (OR: 0.19, 95% CI: 0.060.58, P=0.004) and 73% lower odds of perceiving sufficient resident autonomy compared with nonhospitalists (OR: 0.27, 95% CI: 0.110.66, P=0.004). However, there was a significant interaction between hospitalists and experience; compared with early‐career hospitalists, experienced hospitalists had higher odds of perceiving both adequate intern involvement in decision making (511 years, OR: 7.36, 95% CI: 1.8629.1, P=0.004; >11 years, OR: 21.2, 95% CI: 1.73260, P=0.017) and sufficient resident autonomy (511 years, OR: 5.85, 95% CI: 1.7519.6, P=0.004; >11 years, OR: 14.4, 95% CI: 1.3159, P=0.029) (Table 3).

Secular trends also remained associated with differences in perception of housestaff autonomy (Table 3). Attendings had 49% lower odds of perceiving adequate intern involvement in decision making in the years following duty‐hour limits compared with the years prior (OR: 0.51, 95% CI: 0.29‐0.87, P=0.014). Similarly, odds of perceiving sufficient resident autonomy were 51% lower post‐duty hours (OR: 0.49, 95% CI: 0.280.86, P=0.012). Spring season was associated with 94% higher odds of perceiving adequate intern involvement in decision making compared with other seasons (OR: 1.94, 95% 1.183.19, P=0.009). There were also nonsignificant higher odds of perception of sufficient resident autonomy in spring (OR: 1.59, 95% CI: 0.972.60, P=0.064). To address the possibility of associations due to secular trends resulting from repeated measures of attendings, models using attending fixed effects were also used. Clustering by attending, the associations between duty hours and perceiving sufficient resident autonomy and intern decision making both remained significant, but the association of spring season did not.

DISCUSSION

This study highlights that attendings' perception of housestaff autonomy varies by attending characteristics and secular trends. Specifically, early‐career attendings and hospitalists were less likely to perceive sufficient housestaff autonomy and involvement in decision making. However, there was a significant hospitalist‐experience interaction, such that more‐experienced hospitalists were associated with higher odds of perceiving sufficient autonomy than would be expected from the effect of experience alone. With respect to secular trends, attendings perceived more trainee autonomy in the last quarter of the academic year, and less autonomy after implementation of resident duty‐hour restrictions in 2003.

As Entrustable Professional Activities unveil a new emphasis on the notion of entrustment, it will be critical to ensure that attending assessment of resident performance is uniform and a valid judge of when to entrust autonomy.[27, 28] If, as suggested by these findings, perception of autonomy varies based on attending characteristics, all faculty may benefit from strategies to standardize assessment and evaluation skills to ensure trainees are appropriately progressing through various milestones to achieve competence. Our results suggest that faculty development may be particularly important for early‐career attendings and especially hospitalists.

Early‐career attendings may perceive less housestaff autonomy due to a reluctance to relinquish control over patient‐care duties and decision making when the attending is only a few years from residency. Hospitalists are relatively junior in most institutions and may be similar to early‐career attendings in that regard. It is noteworthy, however, that experienced hospitalists are associated with even greater perception of autonomy than would be predicted by years of experience alone. Hospitalists may gain experience at a rate faster than nonhospitalists, which could affect how they perceive autonomy and decision making in trainees and may make them more comfortable entrusting autonomy to housestaff. Early‐career hospitalists likely represent a heterogeneous group of physicians, in both 1‐year clinical hospitalists as well as academic‐career hospitalists, who may have different approaches to managing housestaff teams. Residents are less likely to fear hospitalists limiting their autonomy after exposure to working with hospitalists as teaching attendings, and our findings may suggest a corollary in that hospitalists may be more likely to perceive sufficient autonomy with more exposure to working with housestaff.[19]

Attendings perceived less housestaff autonomy following the 2003 duty‐hour limits. This may be due to attendings assuming more responsibilities that were traditionally performed by residents.[26, 29] This shifting of responsibility may lead to perception of less‐active housestaff decision making and less‐evident autonomy. These findings suggest autonomy may become even more restricted after implementation of the 2011 duty‐hour restrictions, which included 16‐hour shifts for interns.[5] Further studies are warranted in examining the effect of these new limits. Entrustment of autonomy and allowance for decision making is an essential part of any learning environment that allows residents to develop clinical reasoning skills, and it will be critical to adopt new strategies to encourage professional growth of housestaff in this new era.[30]

Attendings also perceived autonomy differently by academic season. Spring represents the season by which housestaff are most experienced and by which attendings may be most familiar with individual team members. Additionally, there may be a stronger emphasis on supervision and adherence to traditional hierarchy earlier in the academic year as interns and junior residents are learning their new roles.[30] These findings may have implications for system changes to support development of more functional educational dyads between attendings and trainees, especially early in the academic year.[31]

There are several limitations to our findings. This is a single‐institution study restricted to the general‐medicine service; thus generalizability is limited. Our outcome measures, the survey items of interest, question perception of housestaff autonomy but do not query the appropriateness of that autonomy, an important construct in entrustment. Additionally, self‐reported answers could be subject to recall bias. Although data were collected over 8 years, the most recent trends of residency training are not reflected. Although there was a significant interaction involving experienced hospitalists, wide confidence intervals and large standard errors likely reflect the relatively few individuals in this category. Though there was a large number of overall respondents, our interaction terms included few advanced‐career hospitalists, likely secondary to hospital medicine's relative youth as a specialty.

As this study focuses only on perception of autonomy, future work must investigate autonomy from a practical standpoint. It is conceivable that if factors such as attending characteristics and secular trends influence perception, they may also be associated with variation in how attendings entrust autonomy and provide supervision. To what extent perception and practice are linked remains to be studied, but it will be important to determine if variation due to these factors may also be associated with inconsistent and uneven supervisory practices that would adversely affect resident education and patient safety.

Finally, future work must include the viewpoint of the recipients of autonomy: the residents and interns. A significant limitation of the current study is the lack of the resident perspective, as our survey was only administered to attendings. Autonomy is clearly a 2‐way relationship, and attending perception must be corroborated by the resident's experience. It is possible attendings may perceive that their housestaff have sufficient autonomy, but residents may view this autonomy as inappropriate or unavoidable due an absentee attending who does not adequately supervise.[32] Future work must examine how resident and attending perceptions of autonomy correlate, and whether discordance or concordance in these perceptions influence satisfaction with attending‐resident relationships, education, and patient care.

In conclusion, significant variation existed among attending physicians with respect to perception of housestaff autonomy, an important aspect of entrustment and clinical supervision. This variation was present for hospitalists, among different levels of attending experience, and a significant interaction was found between these 2 factors. Additionally, secular trends were associated with differences in perception of autonomy. As entrustment of residents with progressive levels of autonomy becomes more integrated within the requirements for advancement in residency, a greater understanding of factors affecting entrustment will be critical in helping faculty develop skills to appropriately assess trainee professional growth and development.

Acknowledgments

The authors thank all members of the Multicenter Hospitalist Project for their assistance with this project.

Disclosures: The authors acknowledge funding from the AHRQ/CERT 5 U18 HS016967‐01. The funder had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Prior presentations of the data include the 2012 Department of Medicine Research Day at the University of Chicago, the 2012 Society of Hospital Medicine Annual Meeting in San Diego, California, and the 2012 Midwest Society of General Medicine Meeting in Chicago, Illinois. All coauthors have seen and agree with the contents of the manuscript. The submission was not under review by any other publication. The authors report no conflicts of interest.

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Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73:387–396.
Kilminster S, Jolly B, der Vleuten CP. A framework for effective training for supervisors. Med Teach. 2002;24:385–389.
Farnan JM, Johnson JK, Meltzer DO, et al. On‐call supervision and resident autonomy: from micromanager to absentee attending. Am J Med. 2009;122(8):784–788.

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Journal of Hospital Medicine - 8(6)

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292-297

Read more about Attendings' Perception of Housestaff

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Original Research

Author(s)

David O. Meltzer, MD, PhD

Ainoa Mayo, MA

Benjamin Vekhter, PhD

Author(s)

David O. Meltzer, MD, PhD

Ainoa Mayo, MA

Benjamin Vekhter, PhD

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METHODS

Study Design

Data Collection

Statistical Analysis

RESULTS

Table 1.Attending Physician Demographic Characteristics
Characteristics	Value
NOTE: Abbreviations: IQR, interquartile range; SD, standard deviation. a Because of missing data, numbers may not correspond to exact percentages. b Data only available beyond academic year 20032004.
Female, n (%)	275 (47)
Hospitalist, n (%)	125 (23)
Years since completion of residency
Mean, median, SD	9.3, 7, 7.6
IQR	314
04, n (%)	167 (36)
511, n (%)	146 (32)
>11, n (%)	149 (32)
Weeks on service per yearb
Mean, median, SD	8.1, 6, 5.8
IQR	412

Attending Factors Associated With Perception of Trainee Autonomy

Table 2.Attending Characteristics and Time Trends Associated With Perception of Intern Involvement in Decision Making and Resident Autonomy
Attending Characteristics, n (%)	Agree With Intern Involvement in Decision Making	Agree With Sufficient Resident Autonomy
NOTE: Abbreviations: F, female; M, male. a Because of missing data, numbers may not correspond to exact percentages.
Designation
Hospitalist	29 (33)	37 (42)
Nonhospitalist	163 (48)	180 (54)
Years since completion of residency
04	37 (27)	49 (36)
511	77 (53)	88 (61)
>11	77 (53)	81 (56)
Sex
F	98 (46)	100 (47)
M	113 (43)	138 (53)
Secular factors, n (%)
Pre‐2003 duty‐hours restrictions	56 (57)	62 (65)
Post‐2003 duty‐hours restrictions	156 (41)	176 (46)
Season of survey
Summer (JulySeptember)	61 (45)	69 (51)
Fall (OctoberDecember)	53 (42)	59 (48)
Winter (JanuaryMarch)	42 (37)	52 (46)
Spring (AprilJune)	56 (54)	58 (57)

Sex was not associated with differences in perception of intern decision making (²₁=0.39, P=0.53) or resident autonomy (²₁=1.4, P=0.236) (Table 2).

Secular Factors Associated With Perception of Trainee Autonomy

Multivariate Analyses

Table 3.Association Between Agreement With Housestaff Autonomy and Attending Characteristics and Secular Factors
	Interns Involved With Decision Making		Resident Had Sufficient Autonomy
NOTE: Abbreviations: CI, confidence interval; OR, odds ratio. a Multivariate logistic regression model to determine association between sex, years of experience, hospitalist specialty, duty hours, academic season, and the interaction between hospitalist specialty and experience with attending physician agreement with intern involvement in decision making. Similarly, the second model was to determine the association between the above‐listed factors and attending agreement with sufficient resident autonomy. Male sex was used as the reference group in the analysis. Experience was divided into tertiles of years since completion of residency: first tertile (04 years), second tertile (511 years) and third tertile (>11 years). First tertile of years of experience was used as the reference group in the analysis. Similarly, hospitalist*04 years of experience was the reference group when determining the effects of the interaction between hospitalist specialty and experience. The duty‐hours covariate is the responses after implementation of the 2003 duty‐hours restriction. Academic year was studied as spring season (MarchJune) compared with the other seasons.
Covariate	OR (95% CI)	P Value	OR (95% CI)	P Value
Attending characteristics
04 years of experience
511 years of experience	2.16 (1.17‐3.97)	0.013	1.73 (0.96‐3.14)	0.07
>11 years of experience	2.05 (1.16‐3.63)	0.014	1.50 (0.86‐2.62)	0.154
Hospitalist	0.19 (0.06‐0.58)	0.004	0.27 (0.11‐0.66)	0.004
Hospitalist 04 years of experiencea
Hospitalist 511 years of experiencea	7.36 (1.86‐29.1)	0.004	5.85 (1.75‐19.6)	0.004
Hospitalist >11 years of experiencea	21.2 (1.73‐260)	0.017	14.4 (1.31‐159)	0.029
Female sex	1.41 (0.92‐2.17)	0.115	0.92 (0.60‐1.40)	0.69
Secular factors
Post‐2003 duty hours	0.51 (0.29‐0.87)	0.014	0.49 (0.28‐0.86)	0.012
Spring academic season	1.94 (1.18‐3.19)	0.009	1.59 (0.97‐2.60)	0.064

DISCUSSION

Acknowledgments

The authors thank all members of the Multicenter Hospitalist Project for their assistance with this project.

METHODS

Study Design

Data Collection

Statistical Analysis

RESULTS

Table 1.Attending Physician Demographic Characteristics
Characteristics	Value
NOTE: Abbreviations: IQR, interquartile range; SD, standard deviation. a Because of missing data, numbers may not correspond to exact percentages. b Data only available beyond academic year 20032004.
Female, n (%)	275 (47)
Hospitalist, n (%)	125 (23)
Years since completion of residency
Mean, median, SD	9.3, 7, 7.6
IQR	314
04, n (%)	167 (36)
511, n (%)	146 (32)
>11, n (%)	149 (32)
Weeks on service per yearb
Mean, median, SD	8.1, 6, 5.8
IQR	412

Attending Factors Associated With Perception of Trainee Autonomy

Table 2.Attending Characteristics and Time Trends Associated With Perception of Intern Involvement in Decision Making and Resident Autonomy
Attending Characteristics, n (%)	Agree With Intern Involvement in Decision Making	Agree With Sufficient Resident Autonomy
NOTE: Abbreviations: F, female; M, male. a Because of missing data, numbers may not correspond to exact percentages.
Designation
Hospitalist	29 (33)	37 (42)
Nonhospitalist	163 (48)	180 (54)
Years since completion of residency
04	37 (27)	49 (36)
511	77 (53)	88 (61)
>11	77 (53)	81 (56)
Sex
F	98 (46)	100 (47)
M	113 (43)	138 (53)
Secular factors, n (%)
Pre‐2003 duty‐hours restrictions	56 (57)	62 (65)
Post‐2003 duty‐hours restrictions	156 (41)	176 (46)
Season of survey
Summer (JulySeptember)	61 (45)	69 (51)
Fall (OctoberDecember)	53 (42)	59 (48)
Winter (JanuaryMarch)	42 (37)	52 (46)
Spring (AprilJune)	56 (54)	58 (57)

Sex was not associated with differences in perception of intern decision making (²₁=0.39, P=0.53) or resident autonomy (²₁=1.4, P=0.236) (Table 2).

Secular Factors Associated With Perception of Trainee Autonomy

Multivariate Analyses

Table 3.Association Between Agreement With Housestaff Autonomy and Attending Characteristics and Secular Factors
	Interns Involved With Decision Making		Resident Had Sufficient Autonomy
NOTE: Abbreviations: CI, confidence interval; OR, odds ratio. a Multivariate logistic regression model to determine association between sex, years of experience, hospitalist specialty, duty hours, academic season, and the interaction between hospitalist specialty and experience with attending physician agreement with intern involvement in decision making. Similarly, the second model was to determine the association between the above‐listed factors and attending agreement with sufficient resident autonomy. Male sex was used as the reference group in the analysis. Experience was divided into tertiles of years since completion of residency: first tertile (04 years), second tertile (511 years) and third tertile (>11 years). First tertile of years of experience was used as the reference group in the analysis. Similarly, hospitalist*04 years of experience was the reference group when determining the effects of the interaction between hospitalist specialty and experience. The duty‐hours covariate is the responses after implementation of the 2003 duty‐hours restriction. Academic year was studied as spring season (MarchJune) compared with the other seasons.
Covariate	OR (95% CI)	P Value	OR (95% CI)	P Value
Attending characteristics
04 years of experience
511 years of experience	2.16 (1.17‐3.97)	0.013	1.73 (0.96‐3.14)	0.07
>11 years of experience	2.05 (1.16‐3.63)	0.014	1.50 (0.86‐2.62)	0.154
Hospitalist	0.19 (0.06‐0.58)	0.004	0.27 (0.11‐0.66)	0.004
Hospitalist 04 years of experiencea
Hospitalist 511 years of experiencea	7.36 (1.86‐29.1)	0.004	5.85 (1.75‐19.6)	0.004
Hospitalist >11 years of experiencea	21.2 (1.73‐260)	0.017	14.4 (1.31‐159)	0.029
Female sex	1.41 (0.92‐2.17)	0.115	0.92 (0.60‐1.40)	0.69
Secular factors
Post‐2003 duty hours	0.51 (0.29‐0.87)	0.014	0.49 (0.28‐0.86)	0.012
Spring academic season	1.94 (1.18‐3.19)	0.009	1.59 (0.97‐2.60)	0.064

DISCUSSION

Acknowledgments

The authors thank all members of the Multicenter Hospitalist Project for their assistance with this project.

References

Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ. 2000;34(10):827–840.
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988–994.
Kennedy TJ, Regehr G, Baker GR, et al. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10 suppl):S106–S111.
Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, Institute of Medicine. Ulmer C, Wolman D, Johns M, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2008.
Nasca TJ, Day SH, Amis ES; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
Haun SE. Positive impact of pediatric critical care fellows on mortality: is it merely a function of resident supervision? Crit Care Med. 1997;25(10):1622–1623.
Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university‐affiliated emergency departments. Acad Med. 1998;73(7):776–782.
Phy MP, Offord KP, Manning DM, et al. Increased faculty presence on inpatient teaching services. Mayo Clin Proc. 2004;79(3):332–336.
Busari JO, Weggelaar NM, Knottnerus AC, et al. How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting. Med Educ. 2005;39(7):696–703.
Fallon WF, Wears RL, Tepas JJ. Resident supervision in the operating room: does this impact on outcome? J Trauma. 1993;35(4):556–560.
Schmidt UH, Kumwilaisak K, Bittner E, et al. Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology. 2008;109(6):973–937.
Velmahos GC, Fili C, Vassiliu P, et al. Around‐the‐clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients. Am Surg. 2001;67(12):1175–1177.
Gennis VM, Gennis MA. Supervision in the outpatient clinic: effects on teaching and patient care. J Gen Int Med. 1993;8(7):378–380.
Paukert JL, Richards BF. How medical students and residents describe the roles and characteristics of their influential clinical teachers. Acad Med. 2000;75(8):843–845.
Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428–442.
Farnan JM, Burger A, Boonayasai RT, et al; for the SGIM Housestaff Oversight Subcommittee. Survey of overnight academic hospitalist supervision of trainees. J Hosp Med. 2012;7(7):521–523.
Haber LA, Lau CY, Sharpe B, et al. Effects of increased overnight supervision on resident education, decision‐making, and autonomy. J Hosp Med. 2012;7(8):606–610.
Trowbridge RL, Almeder L, Jacquet M, et al. The effect of overnight in‐house attending coverage on perceptions of care and education on a general medical service. J Grad Med Educ. 2010;2(1):53–56.
Chung P, Morrison J, Jin L, et al. Resident satisfaction on an academic hospitalist service: time to teach. Am J Med. 2002;112(7):597–601.
Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366(11):1051–1056.
Ten Cate O, Scheele F. Competency‐based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–547.
Ten Cate O. Trust, competence, and the supervisor's role in postgraduate training. BMJ. 2006;333(7571):748–751.
Kashner TM, Byrne JM, Chang BK, et al. Measuring progressive independence with the resident supervision index: empirical approach. J Grad Med Educ. 2010;2(1):17–30.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
Arora V, Meltzer D. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226–1227.
Arora VM, Georgitis E, Siddique J, et al. Association of workload of on‐call interns with on‐call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146–1153.
Ten Cate O. Entrustability of professional activities and competency‐based training. Med Educ. 2005;39:1176–1177.
Sterkenburg A, Barach P, Kalkman C, et al. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1399–1400.
Reed D, Levine R, et al. Effect of residency duty‐hour limits. Arch Intern Med. 2007;167(14):1487–1492.
Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73:387–396.
Kilminster S, Jolly B, der Vleuten CP. A framework for effective training for supervisors. Med Teach. 2002;24:385–389.
Farnan JM, Johnson JK, Meltzer DO, et al. On‐call supervision and resident autonomy: from micromanager to absentee attending. Am J Med. 2009;122(8):784–788.

References

Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ. 2000;34(10):827–840.
Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15(11):988–994.
Kennedy TJ, Regehr G, Baker GR, et al. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10 suppl):S106–S111.
Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, Institute of Medicine. Ulmer C, Wolman D, Johns M, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2008.
Nasca TJ, Day SH, Amis ES; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
Haun SE. Positive impact of pediatric critical care fellows on mortality: is it merely a function of resident supervision? Crit Care Med. 1997;25(10):1622–1623.
Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university‐affiliated emergency departments. Acad Med. 1998;73(7):776–782.
Phy MP, Offord KP, Manning DM, et al. Increased faculty presence on inpatient teaching services. Mayo Clin Proc. 2004;79(3):332–336.
Busari JO, Weggelaar NM, Knottnerus AC, et al. How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting. Med Educ. 2005;39(7):696–703.
Fallon WF, Wears RL, Tepas JJ. Resident supervision in the operating room: does this impact on outcome? J Trauma. 1993;35(4):556–560.
Schmidt UH, Kumwilaisak K, Bittner E, et al. Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology. 2008;109(6):973–937.
Velmahos GC, Fili C, Vassiliu P, et al. Around‐the‐clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients. Am Surg. 2001;67(12):1175–1177.
Gennis VM, Gennis MA. Supervision in the outpatient clinic: effects on teaching and patient care. J Gen Int Med. 1993;8(7):378–380.
Paukert JL, Richards BF. How medical students and residents describe the roles and characteristics of their influential clinical teachers. Acad Med. 2000;75(8):843–845.
Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428–442.
Farnan JM, Burger A, Boonayasai RT, et al; for the SGIM Housestaff Oversight Subcommittee. Survey of overnight academic hospitalist supervision of trainees. J Hosp Med. 2012;7(7):521–523.
Haber LA, Lau CY, Sharpe B, et al. Effects of increased overnight supervision on resident education, decision‐making, and autonomy. J Hosp Med. 2012;7(8):606–610.
Trowbridge RL, Almeder L, Jacquet M, et al. The effect of overnight in‐house attending coverage on perceptions of care and education on a general medical service. J Grad Med Educ. 2010;2(1):53–56.
Chung P, Morrison J, Jin L, et al. Resident satisfaction on an academic hospitalist service: time to teach. Am J Med. 2002;112(7):597–601.
Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366(11):1051–1056.
Ten Cate O, Scheele F. Competency‐based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–547.
Ten Cate O. Trust, competence, and the supervisor's role in postgraduate training. BMJ. 2006;333(7571):748–751.
Kashner TM, Byrne JM, Chang BK, et al. Measuring progressive independence with the resident supervision index: empirical approach. J Grad Med Educ. 2010;2(1):17–30.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
Arora V, Meltzer D. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226–1227.
Arora VM, Georgitis E, Siddique J, et al. Association of workload of on‐call interns with on‐call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146–1153.
Ten Cate O. Entrustability of professional activities and competency‐based training. Med Educ. 2005;39:1176–1177.
Sterkenburg A, Barach P, Kalkman C, et al. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1399–1400.
Reed D, Levine R, et al. Effect of residency duty‐hour limits. Arch Intern Med. 2007;167(14):1487–1492.
Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73:387–396.
Kilminster S, Jolly B, der Vleuten CP. A framework for effective training for supervisors. Med Teach. 2002;24:385–389.
Farnan JM, Johnson JK, Meltzer DO, et al. On‐call supervision and resident autonomy: from micromanager to absentee attending. Am J Med. 2009;122(8):784–788.

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Journal of Hospital Medicine - 8(6)

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Journal of Hospital Medicine - 8(6)

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292-297

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292-297

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How do attendings perceive housestaff autonomy? Attending experience, hospitalists, and trends over time

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Address for correspondence and reprint requests: Shannon Martin, MD, 5841 S. Maryland Ave., MC 5000, W307, Chicago, IL 60637; Telephone: 773‐702‐2604; Fax: 773‐795‐7398; E‐mail: [email protected]

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