Teaching in the Hospital: How Can We Do a Better Job?

Lenny Salzberg, MD

At the STFM Annual Spring Conference this past May, there were no sessions specifically dedicated to attending in the hospital, despite the fact that our residents spend a significant portion of their training on the wards. In my program, residents spend 30% of their required rotational experiences doing inpatient medicine and night float. As faculty members we need to maximize this third of their residency, and STFM is an important place to capture and coordinate ways to achieve this.

How can we maximize the hospital experience? One strategy is to start with one of Stephen Covey’s Seven Habits of Highly Effective People: Begin With the End in Mind. What do we want our residents to be able to do after they’ve completed their inpatient rotations?

• Recognize when patients are sick
• Have the skills to care for straightforward patients
• Have the skills to care for complex sick patients
• Successfully transition their patients’ care to the outpatient setting
• Move from dependent to independent practitioners
• Have a solid foundation of knowledge to scaffold on

In short, we want them to be competent, compassionate family physicians who can care for hospitalized patients if they so choose.

One way to teach and assess the residents’ ability to recognize “sick” and “not sick” is by naming a team “captain”—one resident to be “in charge” of the service at any given time. The captain is responsible for equitable assignment of patients and for prioritizing the order in which patients are seen during walk rounds. Since patient acuity is rarely equal, equitable assignment of patients relies heavily on the captain’s ability to assess patients’ degree of complexity. Prioritizing the order in which patients are seen demonstrates how well the captain can distinguish “toxic” from “sick” and “not-sick.” It also helps demonstrate how well the captain knows the patients. I give the following directions: “We should see the sickest patients first, patients needing urgent orders next, patients to be discharged following them, then all others. Sometimes proximity or gravity will change the order in which we see patients, but this should be the exception.”

To have the skills to care for their straightforward and complex sick patients, I expect residents to read. I make it clear that this reading should occur both at the point of care and at home. Reading should always include a “skeleton” book (eg, Washington Manual, Ferri’s Clinical Advisor, Up to Date, etc) initially and then a “flesh” book (eg, Cecil’s Essentials of Medicine), or when doing a presentation a “skin” book (eg, ACP’s Scientific American Medicine). We have once weekly rounds with a medical librarian, and residents are given the chance to question our patient management. They are then expected to reference the articles pulled by the librarian in rounds the following day. Residents are expected to have reference materials (eg, The Sanford Guide) available during rounds and are expected to use them. Each week, a resident is assigned a topic to present on rounds. The presentation is brief (5–10 minutes) and is on one aspect of one of their patients’ conditions.

I want to serve as a coach for the residents and to encourage them to practice excellent medicine. One way to make this happen is to alternate walk rounds with sit-down rounds. During walk rounds the intern or resident primarily responsible for the patient presents the patient in their room to the team. During these rounds any significant historical or physical exam findings are reinforced. This helps the residents retain what they have learned by pegging it to an actual patient. STFM is a great forum to develop a family medicine-based approach to inpatient medicine. Including hospital teaching-focused faculty development to future conferences would be a start. What else can we do?

Is this what you do when you are attending? What can I do better? How can faculty development assist with this?