As hospital medicine attracts growing numbers of graduating internal medicine residents, the question of how to best prepare trainees for independent practice during residency remains unanswered. Nationwide, hospitalist elective rotations vary widely in goals and structure.1 Further, despite the field’s increasing collaboration with advance practice providers, only two of 11 identified residency “tracks” for hospital medicine offer resident collaboration with advanced practice providers (APPs).2 This lack of exposure to interprofessional care models during residency comes despite general acknowledgment from hospitalists that graduate medical education leaves them underprepared in interdisciplinary care systems.3 Faculty development efforts and fellowship programs to train new hospitalists and APPs in collaborative care exist but are variable in their intensity, mentorship, and availability.4 After identifying this training gap, we launched the “Transition to Attending Hospitalist” rotation—a two-week elective for senior internal medicine residents and focused on interprofessional teaming with APPs.
We designed this two-week elective rotation to be run at a single academic institution for third-year internal medicine residents entering hospital medicine after graduation. After performing an internal needs assessment based on existing didactic curricula and clinical rotations, a group of medical education experts identified a gap in exposure to APPs and teaming best practices in the current training model. The study was deemed exempt from IRB approval.
The rotation was designed to allow the participating senior resident to functionally replace the attending of record for roughly half the patients on the census of an interprofessional general internal medicine service with two frontline APPs. The resident was granted autonomy to develop care plans with the APPs and instructed to see patients, run the list, and attest APP notes as if there were no supervising attending. Attending physicians were still required to see patients independently and review the care plan daily as they would when working with APPs without residents. Each resident was paired with an APP mentor and received a one-on-one session with the APP site leader to discuss best practices for workflow and communication.
Over the course of the two-week block, the participating resident also received standardized, one-hour facilitated discussions with faculty covering other important elements of daily hospitalist practice. These topics included: leadership skills training, patient triage, billing, documentation compliance, and utilization review. For each session, a facilitator guide was developed that includes debriefing and reflection questions as well as references for further reading.
From 2017 through 2019, 10 residents enrolled in and completed the rotation under the supervision of eight separate hospitalist faculty members. Five out of the seven APPs at this medical center worked with residents on the elective.
Participating residents completed a qualitative post-rotation survey that assessed commitment to future behavior changes that were identified as best practices during this rotation. Graduated residents who completed the elective in its initial year (n=4) were sent a follow-up survey (using a 5-point Likert scale) in their first year as hospitalist faculty to assess the elective’s relevance to their current practice. Attending physicians and APPs on service with rotating residents were, respectively, sent surveys after the elective had been running for 18 months. Two study authors subsequently analyzed the survey data utilizing inductive content analysis.
Six of 10 residents (60%) completed the open-ended, four question post-rotation feedback survey. Questions included “name three things you intend on doing the next time you work on a hospitalist team or with an APP,” “what was most challenging when developing a workflow with APPs,” “name two things you learned about the role of APPs on the team,” and “how was this rotation unique from other ones you have done?” Key themes from resident reflections included surprise at APP independence and desire for learning (n =6, 100%), the importance of clear expectation-setting for workflow (n = 5, 83%), and the value of independent medical decision-making during residency training (n = 4, 67%). One resident, in particular, noted the complexity of interprofessional dynamics outside the traditional hierarchy of academic medicine: “It was difficult to feel responsible for the workflow and decision-making despite being the ‘new kid on the block’ and having less clinical experience than both APPs I worked with…. It made delineating tasks more difficult than it usually is with interns.”
Elective Follow-up Survey
Three of the four graduated residents (75%) responded to the one-year follow-up survey. All survey respondents agreed that the elective helped them better understand the role of an APP and changed the way they interact with APPs.
Four out of five APPs (80%) who worked with residents on the elective responded to the 18-month follow-up survey. All APP respondents either agreed or strongly agreed that they felt comfortable giving feedback to senior residents, their autonomy was preserved, they were still able to deliver safe and efficient patient care, and the residents they worked with better understood the role of the APP on the healthcare team after completing the rotation. Three key themes emerged from APP responses. First, respondents noted the value of continuing education from physician collaborators, especially sharing “teaching points” or “clinical pearls on a topic that might be confusing.” Second, respondents expressed their desire to increase understanding of the APP scope of practice and how APPs differ from residents. Finally, several respondents shared that teamwork (“things like checking in to see if we need help” or “when you see us overwhelmed, asking if [the hospitalist] can do anything at all helps take the load off”) and communication (“if [the hospitalist] made any changes to the plan of care for a patient after we have run the list, please let us know about the changes”) are key.
From the attending surveys, all respondents (n=7, 87.5%) agreed or strongly agreed that they wish they had a similar elective in training. Six out of seven respondents reported that working with a resident did not impede their workflow.
Through the Transition to Attending Hospitalist elective, residents seemed to have obtained valuable insight into the role of APPs on healthcare teams. Specifically, they reported challenges adapting to the new workflow in an unfamiliar, interdisciplinary model. This model, as noted by one resident respondent, challenges the traditional hierarchy of academic medicine and leads to possible role ambiguity, especially for new hospitalists who may have less experience than their APP partners. As not all residency graduates will go on to refine these skills through a hospital-medicine fellowship, we believe leadership training, communication skills development, and increased exposure to interprofessional models during residency will be imperative to future hospitalist-focused tracks or electives. We also feel that it is important to have APPs lead and mentor some of these interactions to ensure their perspectives are well represented.
In their role as mentors, the APPs in this cohort felt comfortable giving feedback to residents and felt that the rotation positively changed resident knowledge of their role on the team and affirmed their desire to learn from supervising physicians. The surprise expressed by participating residents at the premium placed on teaching by the APPs suggests to us that this space is also ripe for future interventions.
Our pilot study does have significant limitations, including a small sample size at a single institution, lack of a comparator group, and inability to draw any true conclusions due to limited statistics. Additionally, residents at programs with less attending supervision on medicine rotations may not find the autonomy that this elective offers as novel, although they may still benefit from the APP exposure.
Overall, we found that residents seemed to enjoy the increased autonomy and were challenged by balancing their own clinical care while respecting the autonomy of their APP partner. APPs seemed to find this elective was an effective means of educating residents about their role on the team. We hope that the discoveries identified by this collaborative care pilot project encourage additional interprofessional experiences for internal medicine residents and identification of teaming best practices. We feel this rotation is transferable to other institutions and provides a unique and valuable experience for residents going into hospital medicine.