Who runs rounds—the senior resident or the attending? And how many patients should a medical student follow?
Questions like these made us realize we had not clearly defined expectations on our wards’ teams. In addition, there were situations where learners felt they received below-average evaluations or negative feedback because they did not understand the expectations of the rotation. We might assume that faculty and learners know what is expected of them. However, medical students report feeling like they are constantly being evaluated and the feedback process is arbitrary and subjective.1 Struggling learners benefit from setting clear expectations early and providing ongoing feedback around expectations.2 Additionally, when faculty are aware of what is expected of them, they are more likely to improve their performance as clinician educators.3 Due to a scarcity of uniform, clear expectations on the wards teams at our institutions, we created and piloted an expectations sheet to set a standard for all members on an inpatient general medicine service.
Below are the five steps we followed:
1) Convenience Sample Gap and Thematic Analysis
We initially gathered expectations sheets from 14 Division of Hospital Medicine (DHM) faculty. Ranging from 1-4 pages, they were aimed at different types of teaching teams (medicine wards, acute care of the elderly, etc.). There were differences in structure (e.g., bulleted v. paragraph form), level of detail (e.g., “I will teach for 10 minutes” v. “teaching will occur”), and rounding style preferences (e.g., hallway v. bedside and formal presentation v. pertinent facts only).
Next, we identified common sections or themes. Most expectations sheets started with an overall vision statement identifying broad team goals and objectives. This was typically followed by sections detailing specific expectations for attendings, senior residents, interns, and medical students. Additional sections included details on rounding, teaching, when to call your attending, and diversity, equity, and inclusion statements.
2) Engagement of Key Stakeholders
We solicited feedback from stakeholders including leadership of the Division of Hospital medicine, the Internal Medicine Residency Program (IMRP), the School of Medicine (CUSOM) and the Hospital Medicine Advanced Practice Fellowship (HMAPF). We wanted to ensure that the expectations we crafted matched the expectations each program had already set for their learners. These conversations highlighted the specific needs of each group.
A priority for the School of Medicine was ensuring that there was a clear distinction between these expectations and the specific clerkship grading criteria that were provided to students. We also discussed the idea of prescriptive formats and time limitations for presentations. We had an opportunity to collaborate with the medical school to create shared expectations as they were revising their own expectations. From the IMRP perspective, priorities included ensuring rounds ended on time, interns could focus on patient care, attendings were available after rounds, and the team had faculty support for smooth discharges, especially on “intern only” days. Our meeting with the HMAPF leadership helped us draft a description of the role of nurse practitioner and physician assistant fellows on a wards team given many residents and medical students had not previously worked with Advanced Practice Fellows.
3) Standardized Expectations Sheet Development
The expectations sheet begins with a section where faculty can provide contact details and personalize their philosophy towards wards and team culture. This is followed by individual team member sections that detail each member’s responsibilities from second-year medical students to attending physicians. Each section begins with a brief description of the team member’s role within the team. The attending’s role description reads “The attending’s main job is to coach and support the team in delivering excellent patient care while providing opportunities for teaching and feedback” and serves as an example for additional role descriptions. Subsequently, a series of specific expectations are listed for each role. Specific expectations are centered around efficiency, responsibilities, and communication. Regarding responsibilities, learners want to know “who does what” so that they can better understand what they are responsible for and how to prioritize their daily tasks. For example, many interns want to teach medical students, but their priority was direct patient care tasks, such as calling consults and putting in orders. Medical teaching can occur after duties to the patient were finished.
Following descriptions of individual roles, presentation formats detailing recommended content and dedicated time for an initial H&P vs. subsequent encounters are provided. Additional sections cover expectations regarding education, conference attendance, “when to call your attending,” and a diversity, equity, and inclusion clause.
4) Management of Conflicting Priorities
As we created our expectations sheet, we identified conflict prone topics that needed special attention. First, consider which items were of universal importance versus attending personal preference. We agreed that this section including the attending’s vison statement could be personalized. However, to standardize expectations, the remaining document was not be edited. We identified the idea of a firm ending time for rounds each morning to be the most contentious topic. At our institutions, rounds typically begin 8:00-8:30 am, with a required noontime educational conference for learners. The CUSOM and IMRP favored a strict end time of 11:00 am for rounds, facilitating attendance at educational conferences while still having sufficient time to complete clinical tasks. Many attendings were supportive of a cutoff time, while others were opposed to it. Upon prolonged deliberation, we opted to recommend for rounds to be completed by 11:00 am.
5) Implementation and Adaptation
We originally asked a few hospitalists, residents, and medical students to pilot the expectations sheet on medicine wards and to provide us feedback. Currently, the expectations sheet is shared electronically with all learners and faculty rotating on inpatient wards teams at the beginning of their rotation. It has been presented as the standard at DHM business meetings and is also introduced to new faculty during their orientation to the division. Faculty are encouraged to add their own vision and review with learners at the start of the rotation. Whether or not faculty are routinely reviewing the expectation sheet with learners, our division intends to use it as a reference if any issues around roles and expectations on our wards teams arise. Next steps may include a survey of faculty to assess for: 1. awareness and utilization of the expectations sheet; 2. challenges or barriers for its use; 3. opportunities for improvement.
Though individual programs may have expectations for their learners, these expectations are often not presented in a uniform way to faculty and learners. A universal expectations sheet is an important tool to set a clear performance standard on medicine wards, clarify team members roles and responsibilities, and provide a guide for remediating the struggling learner or faculty member.