Service and Education: The Association Between Workload, Patient Complexity, and Teaching on Internal Medicine Inpatient Services

Abstract

Background: Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds. Objective: To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables. Design: Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks. Participants: Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students. Main Measures: The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission. Key Results: We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549] = 6.90, p < 0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient’s admission; F[8,548] = 14.18, p < 0.001). Conclusions: Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.