• Current Issue
• ACP Hospitalist Weekly
• Supplements
• Blog
• Archives
  • By Topic
• Career Connection
• Subscribe
• RSS Feeds

Residency redesign helps patients and pleases doctors

From the August ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Stacey Butterfield

Sidebar: Failure within a success

Where: The 72-bed medicine ward of Boston's Faulkner Hospital, a community teaching hospital affiliated with Brigham and Women's Hospital.

The issue: Increasing the educational value of residency for trainees while not compromising patient care.

Background

The leaders of the Brigham and Women's residency program had a growing sense that their trainees were getting a less-than-ideal educational experience, with much of their time taken up by patient care to the detriment of learning.

“We felt like our trainees were being consumed by the rapid turnover of patients, the high patient load, and the turnover of the residents with the duty-hour require- ments.” —Graham T. McMahon, MD

“We felt like our trainees were being consumed by the rapid turnover of patients, the high patient load, and the turnover of the residents with the duty-hour requirements,” said Graham T. McMahon, MD, assistant professor of medicine at Harvard Medical School and physician at Brigham and Women's. “We resolved to see if we could come up with a different way of doing things that might optimize the educational experience while at the same time studying whether it might actually make a difference for patients.”

How it works

The program leaders designed an experimental general medicine service, which they called the Integrated Teaching Unit (ITU). Two teams were created, each with two attendings (one hospitalist and the other an internist or specialist), two residents and three interns. Each team conducted bedside rounds together every morning, and at least one of the physicians conducted additional teaching and reviewed the trainees' progress at the end of the day. The interns also had less frequent call than normal—they were on all night every sixth night, instead of covering until 10 p.m. every fourth night. The patient load for the team was capped at 15.

Results

After a year, the educators compared the new model with the usual system (one resident, two interns, multiple attendings per team) in a study published in the April 8 New England Journal of Medicine. Trainees on the new teams were more satisfied, spent twice as much time in learning activities and had significantly fewer patients at a time (average census of 3.5 patients per intern vs. 6.6).

The satisfaction of both attendings and trainees with some of the changes was also observed anecdotally. “The dual-attending model was very popular with everybody. Going back to bedside team rounds, which has become a vanishing entity in U.S. medicine, was also very popular,” said Dr. McMahon. There was support even for some of the changes that the program designers had not expected trainees to like. “The fact that they were on call through the night, when they were on call, was not as unpopular as we thought at all. In fact, our interns appeared to appreciate that continuity,” he said.

How patients benefit

The really unexpected results appeared when the researchers compared patient outcomes between the two teams. On the ITU service, 26 patients (or 1.4%) died, compared to 48 (2.3%) of those treated normally. “We were personally very surprised that there was such a difference in overall patient survival,” said Dr. McMahon. “When we adjusted for everything from case mix to complexity of the patients or their other factors, it still was highly significant.”

The gains in survival were also accomplished with no loss in efficiency. The differences weren't significant, but length of stay and 30-day readmissions on the ITU service were lower than both the regular service and national averages. “The general concern before we ran the study was that if you cap teams at a census cap—in this case 15—then the teams will have little incentive to discharge patients efficiently,” said Dr. McMahon. “We found the opposite.”

The challenges

Although the project had many successes, not every aspect of the intervention worked out, such as a plan to group patients being cared for by a team in one area. “We worked hard to try to regionalize patient care into the team-based pods and we simply couldn't make that work,” said Dr. McMahon. A planned post-discharge follow-up clinic also didn't work out (see sidebar).

Lessons learned

The results of the experiment indicate that a new model of residency training is possible, and given the patient mortality statistics, maybe necessary. “One of the implications of those two numbers [26 vs. 48 deaths] is that the current standard of inpatient residency care could be improved,” Dr. McMahon said.

The researchers also calculated the costs of the program, and concluded that the extra spending, on attendings' salaries and providers (such as physician assistants) to care for patients who would otherwise be treated by residents, could be mostly offset by cost savings from shorter lengths of stay on the ITU since the hospital was readily able to fill empty beds. “Ultimately, the program was going to cost us, after all the deductions, less than approximately $100,000 per year,” said Dr. McMahon.

“We went out and showed that not only can you do this, but that thoughtful investment in resident education can result in improved patient care, improved resident satisfaction and improved efficiency, all at the same time,” Dr. McMahon said.

Next steps

The program has been expanded from Faulkner Hospital to the main Brigham and Women's hospital, and program leaders continue to track the results. “The data appears to be holding. Even when we took it out of a community hospital and put it in a major academic center, we're starting to see very similar improvements in length of stay and efficiencies,” said Dr. McMahon.

Words of wisdom

“Remember that trainees are there to learn and to work to learn,” Dr. McMahon said.

Top

---

.

Failure within a success

When educators at Brigham and Women's Hospital were developing their experimental model of residency, they decided to include a post-discharge clinic, where patients who had been treated and released by the medicine service could receive follow-up care from the residents.

“The idea was that some of our patients have no primary care physician, and some of our patients have great difficulty getting back in to see their primary care physician and were being left in a limbo between discharge and their next doctor's office visit,” said Graham T. McMahon, MD, assistant professor of medicine at Harvard Medical School.

The project leaders also thought the experience would be good for the residents. “Because patient hospitalizations are so short, residents don't really get to see the spectrum of the disease that they're caring for. They don't get to see their patients really substantially improve as a result of the decisions that they make and don't get to see the impacts of the discharge plan that they come up with,” Dr. McMahon said.

But the reality turned out much different from their expectations. “It didn't work very well at all. In fact, it was probably the most unpopular thing that we did,” said Dr. McMahon.

One problem was that the outpatient visits were difficult to fit into the schedule of inpatient medicine. “The team might be seeing a patient in the emergency room or on rounds in the morning, or going to an educational conference and they'd get a call saying, ‘Mrs. Smith is here for her post-discharge clinic. Will somebody come and see her?’”

Even when the follow-up visits were scheduled in advance for times that should have been convenient, the residents found the transition from one practice environment to the other time-consuming and dissonant, Dr. McMahon said.

The clinic also failed to provide the sense of fulfillment for residents that the educators had expected. “Residents want to be done with a patient when they discharge,” said Dr. McMahon. “Adding that additional expectation that you think about and care about patients after you discharge them was a mind shift that our residents found very difficult to accept and, in fact, resented and pushed back against quite strongly.”

To top it off, even the patients didn't like the clinic, Dr. McMahon said. “It seemed disruptive to the patient. They didn't know who their doctor was: Should they be going to a primary care doctor now? Should they come back to this clinic? Who should they be trying to get in to see when they have a problem?”

“In general the program had more challenges than successes,” said Dr. McMahon. Consequently, the researchers discontinued the follow-up clinic experiment.

Top

Share

 

Hospitalist Archives
Quick Links

ACP Hospitalist Weekly

From the February 8, 2012 edition

• Score predicts outcomes of using IV alteplase with stroke patient
• CT angiography as good as MRI to predict recurrent stroke

View issue

Cartoon Caption Contest

ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Prepare with the Experts: Live Recert Prep Courses from ACP

ACP Launches Depression Care Guide

© ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated