A comprehensive redesign of a pediatric inpatient teaching service which included a formal job description, a significant focus on resident and medical student education, and salary support, led to improvements in multiple educator performance ratings. We have demonstrated improvements in feedback and evaluation of both residents and medical students. In addition, students and residents ratings of the quality of bedside and didactic teaching was more likely to be considered “superior.” We achieved these positive changes in our teaching program through the thoughtful development of defined roles and expectations for faculty in each attending role, as well as offering salary support for accountability for teaching efforts. By doing so, we have been able to move our teaching program forward in many ways. Our inpatient attending coverage has continued to evolve into a smaller group of more dedicated faculty – with an average of 23 faculty per year required to fill all the medical student teaching attending and ward attending responsibilities in the 2008–2011 academic years. The design of our service continues today and remains highly successful in terms of providing clinical care and education to residents and medical students.
While hospitalist systems have also been able to demonstrate effective teaching, our system is a different clinical care model. Our faculty group represents both generalist and subspecialty faculty attendings, all of whom have other aspects to their career, such as ambulatory care and subspecialty clinical care, research, educational administration, clinical program building, and teaching
[14–17]. Our institution currently does not have an academic division of hospital medicine. Our current model hybridizes the benefits of a traditional ward attending service, which includes enhancing resident autonomy and ownership in decision making, along with participation of faculty from subspecialty and general pediatrics, while including additional hours of dedicated attending time for teaching and clinical care. Our hybrid model allows individual faculty to contribute part of their overall effort to the general service yet maintain their home in their academic division. We facilitate this community of ward and teaching attending faculty through faculty development sessions throughout the year on such topics as giving and receiving feedback, small group teaching and improving bedside teaching.
Our program change has also allowed us to achieve important increases in the residents’ and students’ perceptions of the characteristics of the best clinical teachers previously documented in the literature. These include professionalism, punctuality/timeliness, communication and the conveying of clear expectations. The extent of the combined teaching and clinical roles of our faculty ward attendings allows for sufficient time with residents, thus providing a uniform exposure to enhance role modeling
[18, 19]. This may help to shape the eventual teaching skills and career choices of our residents and medical students.
To our knowledge this is the first formal report of wide scale implementation of a teaching attending program for medical students on an inpatient service. Previous brief reports have demonstrated the value of dedicated faculty shifts focused on medical student and resident teaching in an academic emergency department
. As a result of this change, we have documented significant changes in the students’ perception of the quality of bedside teaching. Our students, like others, continue to seek more direct observation of their skills, and faculty continue to struggle with challenges of dedicating the substantial amounts of time needed to view entire patient workups or to pre-round with medical students. The medical student teaching attending program has been able to reverse some of the declines in bedside teaching that have been documented in the literature over the past decades
Strengths of our analysis include the anonymous evaluation system assessing multiple domains and our high evaluation response rate. Student and resident anonymity in our evaluation system limited any concerns that learners would be wary of retribution for criticism. Furthermore, students and residents were unaware that this program was being studied. We assessed the program over two years in order to show sustainability of our findings. In fact, for important domains such as feedback, there was a stronger impact in the second evaluation year compared to the first.
Some study limitations exist. With the exception of the analysis of the medical students’ National Board of Medical Examination clinical subject exam scores, our E*value survey instruments have not been validated. Another possible limitation is the possibility that medical student ratings of their residents and attending teachers may be subject to temporal improvements. To address this, we analyzed whether resident teachers were rated more favorably by medical students over two subsequent years with the new teaching attending program in place. No significant changes were noted in medical student evaluations of the resident teachers during this time (data not shown).
Finally, it’s conceivable that faculty evaluations may have improved on the basis of which faculty members were selected as teaching faculty for this redesigned service. We did not, however, see changes in all of the evaluation domains as may have been expected with an extremely popular and skillful set of teachers. Despite this potential limitation, our department has always approached the changes to the inpatient services as that of a multi-faceted program. This is to say that, without this intervention, we would not have been able to recruit and retain quality faculty teachers. The elements of the program such as clear expectations and salary support, along with faculty development sessions, have enabled us to achieve our goal of significantly improving our teaching program.
Our challenges relate to ongoing funding of this educational program in a tentative environment. Given the reality of low professional fee reimbursement for the clinical activities of the ward attending in Maryland, this service is not able to fully cover the 3.0 full-time equivalent salary needs. While teaching attending activities are not billable, our ongoing analysis of ward attending clinical collections over the last full academic year (2011–2012) demonstrates an offset of approximately 65% of the total salary costs of this program. As a result of this, continued departmental funding and funding from the School of Medicine is necessary. Given the current financial environment, this funding may be threatened in the future and such a system may need to demonstrate more objective educational outcomes and/or changes which enhance clinical efficiency and patient safety in order to gain wide support.