Hospitalists' path to becoming the best educators in the hospital.

Hospitalists are increasingly assuming a primary role in medical education in the hospital setting, as they also steadily care for a larger portion of hospitalized patients. This issue of the Journal of Hospital Medicine highlights the role of hospitalists as teachers in academic medical centers, confirming their expanding and positive role in resident and medical student education. A survey of academic medical centers, a systematic review, an evaluation of the implementation of an educational curriculum, and a survey of residents hint at the challenges hospitalists face in teaching, but also expose us to a more advanced yet facile approach to evaluating the effectiveness of a teaching intervention. These publications provoke interesting questions about clinical teaching that hospital medicine educators and researchers should pursue answering. I believe they will also encourage us to innovate in medical education and assessment of that teaching. Traditionally, teaching attendings for resident teams on medicine or pediatric services rotated through these duties for 1 to 3 months each year, while spending the majority of their time in clinic or research activities. The increasing complexity of hospitalized patients and the pressure to reduce length of stay prompted closer oversight of trainees. With the advent of resident work-hour restrictions, the need for greater clinical involvement by attending physicians made it increasingly difficult to maintain the traditional model of limited engagement by faculty attendings. Simply put, the dwindling pool of willing and able teaching attendings encouraged teaching hospitals to employ hospitalists to fill the gap in teaching and supervision, as well as clinical coverage. Beasley et al. report that resident work-hour restrictions were associated with an increase in the number of teaching hospitals employing hospitalists to 79% of 193 surveyed hospitals in 2007. Of those hospitals with hospitalists, 92% reported that hospitalists serve as attendings on the teaching service. Hospitalists also teach in a number of other venues within these programs, including formal teaching rounds without direct care responsibility, along with delivering didactic lectures and clinical skills education. How well are teaching hospitalists performing compared to traditional teaching attendings? Natarajan et al. provide an important summary of the evidence in a systematic review of studies comparing teaching efforts of hospitalist attendings to those of nonhospitalist attendings. Eight studies from a variety of institutions measured trainee (resident or medical student) attitudes. It is gratifying to learn that hospitalists were generally rated higher at overall teaching effectiveness, provision of feedback, knowledge base, and involvement of the learner in patient care. It seems likely that publication bias would overestimate the positive effect of hospitalists on learner attitudes. However, there are plausible reasons that the positive effect is accurate. Because their professional responsibilities are focused in the hospital, hospitalists should naturally be more available to learners for teaching and feedback. Hospitalists tend to be younger in their academic careers, placing them closer to the cutting edge of knowledge gained during residency and possibly fellowship. They may be more in tune with the needs and pressures faced by their learners, having dealt with these same challenges either during recent training or during ‘‘nonteaching’’ rotations. As a relatively young specialty with young and developing academic hospitalists, will the advantage suggested by the Natarajan et al. systematic review be sustained over the long term as careers in hospital medicine mature? A 2005 systematic review studying this question among practicing clinicians found, somewhat paradoxically, that older, more experienced clinicians appeared to be at risk for providing lower-quality care. To avoid this decline in clinical effectiveness, hospitalists should proactively seek innovative ways to refresh and update their knowledge and skills throughout their careers. This is particularly critical for teaching physicians. We should seize the opportunity to study the relationship between advancing clinical/teaching experience and educational quality within our teaching programs. The review by Natarajan et al. should also challenge the hospitalist community to achieve even higher levels of proficiency as teachers of medicine. The review alludes to bedside teaching and attention to psychosocial aspects of care as opportunities for improvement by hospitalist teachers. A recent study suggested that physical examination instruction receives declining attention from inpatient teachers and that there are opportunities to increase the amount of bedside teaching. A provocative study of inpatients admitted to a teaching service found that physical examination could substantially impact patient care, but that trainees often failed to appreciate significant findings on initial