Addressing structural issues
The attending has a large stake in ensuring that the structure of the rotation is conducive to education and clinical service. If it is not, accomplishing all of the goals and objectives of both clinical service and education will be impossible, and education will be lost. The critical components of a teaching service that are a concern for the attending include the following:
The attending should advocate that his time be protected to ensure that he can fulfill his primary responsibilities during the rotation: patient care and education. This will be particularly challenging for the traditional internist who still manages a clinic during ward teaching assignments, and for the subspecialist who attends on the wards but still has procedures to perform in the afternoon. Even for hospitalists who have additional job requirements (such as committees and preoperative care) this may be a challenge. Where possible, committee meetings should be rescheduled during the month and other professional responsibilities (writing papers, participating in conference calls, compiling business reports) deferred.
The attending should advocate strongly for having protected time from these responsibilities when attending on a busy teaching service. While time is money, nothing is more costly than adverse patient events or loss of a training program's accreditation.
The attending physician should advocate that the residency and student programs construct a system that is time efficient. The ideal training environment should minimize fragmentation of the learner's time (for example, having residents attend morning report, then one hour of attending rounds, then noon conference, then wards, then clinic). The ideal schedule of the day should maximize the high-yield times of clinical decision-making (for example, mornings are not occupied by clinics or conferences). The resident and student schedules should be constructed such that the effect of learner absences is mitigated (so that all learners are not in clinic at the same time or have the same days off). On an attending's first teaching assignment, these issues will be out of his sphere of influence and the best of the situation has to be made. Over time, however, the attending physician should advocate for change to ensure that the hospital teaching environment allows for resident and student focus, which are requisite for successful patient care and teaching.
The attending physician should advocate for a rotation length that is conducive to accomplishing his goals. Too many consecutive weeks on an inpatient service may preclude office-based practitioners from inpatient attending, and will lead to a piling up of office work and outside duties. Conversely, the attending may lose the economy of scale that goes with assignments of two weeks or less. Time is wasted with frequent attending turnover as the attending tries to both learn the new patients and assess the needs of the team. Educational value is also diminished with short assignments because the attending loses track of what the team must be taught, where skills deficits might exist, and where remediation strategies might be required.
Regardless of the system, attendings should adapt by synchronizing their daily schedule with the residents' and students' schedules. Office hours should be truncated or blocked out. Committee meetings should be moved to the windows of time when the resident-student team is by definition without the attending (morning report, noon conference, or resident-only work rounds). Conversely, attendings may want to ensure that they are on the wards when the supervising resident is not (the resident's days off or clinic times). This will ensure efficiency and safety in patient care, as younger learners often defer management decisions when supervisors are not present. It is very important that attendings cancel all other obligations on the post-call days—the intensity will be high on these days, and the resident team will not be around to facilitate patient care in the afternoon.
Time management strategies
Today's attending is faced with an unprecedented challenge in balancing the service requirements and ensuring educational excellence for her team. To accomplish this goal, time management strategies are a must.
For systems that allow remote access to the electronic medical record, the attending should invest in the software and home computer to enable “spying” on the patients' laboratory values from home. While “spying” sounds devious, it is important that the attending exercise stealth in observing laboratory data, lest the team come to expect that their failure to follow the laboratory values will be offset by the attending's doing the job.
Upon waking up, the attending can gain insight into the service size and intensity, and can find answers to several questions that otherwise would consume the first part of the day at work: Were new patients added to the service? If so, how many? Did the patient's condition change? Are any patients ready for discharge? With these insights, the attending can mentally prepare himself on his ride into the hospital for how the rounds will be conducted that day, how much teaching time will be available, and what topics might be addressed in teaching sessions.
Attendings should round alone on early discharge patients. Upon arrival at the hospital, the attending's first task should be to visit patients who have a high probability of being discharged that day. This will allow the attending to start attending rounds with these patients and, if necessary (see below), splitting off one team member to quickly write the discharge order to get the process in motion. As with the laboratory values, the attending should exercise due stealth, lest the team members lose the impetus for diligent rounding on their own.
Attendings should avoid splitting the team unless absolutely necessary. Team rounds (all learners present for all patients) instill the hidden curricular message of the importance of team-based care, enable all learners to expand their patient-care database, and enable the continuity of care when one team member is absent. Routinely rounding with only a portion of the team (such as just the resident and then just the intern) will appear to save time in the short run, but the time saving is largely offset by the confusion over team management that results. In the long run, especially when one team member has off, the time loss due to inefficiency will exceed whatever time was saved by splitting the team. However, when a quick task can be performed, as in a quick discharge order, allowing a team member to be temporarily absent to accomplish this task is time efficient.
The exception to this rule may be on post-call days in systems that still use the 24-hour call system, especially on teams with more than one intern. Here all team members must leave within six hours of the call completion, and it may be most efficient to round with the resident, students, and one intern, allowing the other intern to complete patient care duties (and then vice versa with the second intern). This still maintains a core of the team while enabling the team to leave the hospital under the work-hours regulations.
The attending can ensure her own time efficiency by teaching the team to be more efficient and independent. An efficient team will maintain patient throughput and provide the attending with the data necessary for her own clinical decisions. For systems that provide time for the residency team to round as a unit before meeting with the attending, the attending should stress the importance of the team's arriving at attending rounds with a plan for each patient. Where there is diagnostic uncertainty, the team should arrive committed to a hypothesis about the diagnosis. Nothing wastes time as much as a disorganized, undirected discussion about patients on rounds. Even if the team's decision or hypothesis was wrong, the conversation will quickly hone to the issues that need correcting.
The attending must know how to remediate deficits in oral communication. As stated above, disorganized and verbose student and resident presentations can destroy the efficiency of rounds. As with time management training, the attending can be exponentially helpful in his efforts by teaching the residents these skills, with the directive that they are responsible for teaching the other team members.
Attendings should reserve billing, coding, and documentation for the afternoons and devote rounds to the education of the team. Using attending rounds as a venue where learners watch the attending document patients is painful, eroding the teaching time of the residents and destroying the team's morale. It also lengthens attending rounds, which pushes the residents' “action time” (where they actually do the tasks assigned on attending rounds) into the afternoon, outside of the window of efficiency for making things happen. The better approach is to reserve attending rounds for education and management decisions. The billing, coding, and documentation requirements will vary according to the system in which the attending works. If the system allows, the attending should use linking notes that enable billing and coding from the resident's or intern's documentation. This will not only save time but also ensure that the attending is critically reviewing the resident's notes.
Attendings can offer to see patients twice. One of the perils of rounds is the time lost because of the verbose patient. Outside of patients with axis II mental disorders, verbosity usually has one of two causes: 1) the patient is having a hard time expressing what she wants to say and, feeling misunderstood, repeats the same information in different ways, or 2) the patient is nervous that he will have only one opportunity to talk to his doctor and, with pressured speech, tries to fit all questions and comments into one session.
The result of this pressure, of course, can be a jumble of words that make the patient feel misunderstood; this, in turn, feeds back into the first cause of verbosity. The attending can offset both causes by three approaches.
First, sitting or kneeling down while at the bedside gives the impression of greater time at the bedside and alleviates some of the pressure to “get it all in quickly”—a seated physician does not appear to be about to leave the room as a standing physician does. Second, the attending can assure the patient that whatever is not addressed in this session can be discussed in the afternoon session when he returns. This alleviates the pressure, allowing more linear speech with less anxiety. Finally, repeating the patient's message back to him assures the patient that he has been heard and understood, alleviating the verbosity due to the first cause.
The other advantage to seeing patients twice, even if the second encounter is just a brief visit in the afternoon, is that it enables a quick response to any changes in the patients' condition. It is more time efficient to catch and solve small problems early, before they become big problems. Patients who improve can be identified, and patients with diagnostic information that becomes available in the midafternoon (for example, a negative stress test result) may be eligible for discharge earlier, thereby decompressing the following day's rounds.
Late afternoons on post-call days are an optimal time to call the patients' primary care providers. The attending will be alone during such times because the team will have retired early (as a result of work hour requirements), and primary care providers are probably winding down their clinic schedule. Making calls at the end of the day can save time— there is a greater chance of talking directly to a primary care provider rather than playing phone tag. Not only is calling the primary providers important to begin the transition of care for patients recently admitted, but it can also prevent duplication of diagnostic tests and improve understanding of patient personalities and wishes in subsequent management.
Rounding a second time during on-call days can save time. This allows the attending to hear about patients admitted during the first 10 hours of the call day. Early discharge may be possible for some, thereby decompressing the post-call day. The resident team's presentations are likely to be more cogent than they will be after a night on call; the residents can establish a plan for these patients that only needs to be reviewed the following day. This, too, decompresses the time pressures of the post-call day. By instituting evening on-call rounds, the morning on-call rounds can be truncated, if necessary, permitting the team to deal with admissions earlier (instead of being tied up in morning rounds). This approach in turn accelerates patient care. Evening on-call rounds also enable a more relaxed teaching environment to address some of the more complex clinical issues.
After completion of afternoon rounds alone, it saves time to touch base, even if by phone, with the resident leading the team. Some patients might be eligible for discharge, and the ones who are close to discharge can be reviewed with the resident. This discussion enables the resident to make early-morning discharge decisions based on contingency plans: “Mr. Panda looks much better. If his hemoglobin remains stable tomorrow morning, let's plan on discharging him during your morning work rounds.” Any late diagnostic information can be acted upon with the resident team, thereby advancing care a day earlier as opposed to waiting for the following day's rounds: “Mrs. Phillips' CT scan came back nondiagnostic. I think we need to put her on the schedule for bronchoscopy tomorrow. Will you call the pulmonary fellow and do that?”
Dealing with heterogeneity of the team
As opposed to a teacher in the ambulatory environment, the inpatient teaching attending must regularly deal with the heterogeneity of her learner team. A range of learner levels (ranging from students to residents) and interests (nonmedicine, general medicine, medicine subspecialties) will probably be present. There are three methods for addressing this heterogeneity.
Shifting higher-level learners into a different gear
The attending should not overestimate how much upper-level learners know. The nature of graduate medical education is that learning opportunities (patients) present randomly. Depending on the patients admitted during the call days, it is possible that a resident, despite two or three years of training, may not have seen even the most important inpatient problems (such as diabetic ketoacidosis). Further, even residents with solid foundations of understanding disease may have been corrupted over time by bad or sloppy methods. For this reason, the attending should not feel guilty about teaching even the most basic of internal medicine topics.
However, the attending should be sensitive to the resident's ego and her responsibility for maintaining a position of authority over the team. This conundrum can be easily escaped by leading into the topic by addressing the resident with, “Since you are a resident, I know you know this, but as I talk, I want you to think of how you would teach it.” This shifts the resident into an ego-neutral gear, allowing her to indeed focus on the teaching method if she knows the topic, or to learn the topic (or relearn a proper method) if she does not.
Providing progressive learning that is proportional to difficulty
For the middle-of-the-road topics, the attending can deal with the heterogeneity of the team by a progressive increase in the questioning that parallels the difficulty of the topic. During this process, it is important to recognize the team dynamics. Asking questions that are too difficult will naturally lead to wrong answers, embarrassing the learner. This is especially true for the team leader (the resident). If the leader is made to appear incompetent, it will destroy the team leader's morale and erode the team's effectiveness when the attending is not present. As the line of questioning escalates, it is important that lower-level learners (students) are not confused. The attending can offset this risk by asking the lower-level learners if they understand the content or by explicitly “mentally dismissing” the lower-level students by saying, “This is more at an intern/resident level, so don't worry if you don't get this.”
Taking advantage of days off, clinic absences, and class absences
In terms of team composition, the team will vary from day to day because of days off and clinic or class obligations. The attending can turn this curse into a blessing by selectively planning teaching topics on the basis of levels of difficulty. The day that the resident has off, for example, is the ideal time to talk about fundamental topics; on the intern's day off, the attending may choose topics that are directed toward the students; more complicated discussions can be reserved for days when only the resident is present. The point is, be adaptable, be able to improvise, and, by all means, “teach to your learners.”