In the Literature
Study design: Cross-sectional.
Setting: More than 3,600 hospitals participating in the Health Quality Alliance (HQA) program.
Synopsis: Investigators looked at a large sample of HQA hospitals in the American Hospital Association survey, and identified facilities with hospitalist services and those without. The primary endpoint was the adherence to composites of standard quality process measures across three disease categories (AMI, CHF, and pneumonia) and two domains of care (disease treatment/diagnosis and counseling/prevention).
Multivariable analyses revealed a statistically significant association between the presence of hospitalists and adherence to composite quality measures for AMI and pneumonia. This association was demonstrated for both treatment and counseling domains.
The study is cross-sectional, so conclusions cannot be drawn about causality. Also, there are likely unmeasured differences between hospitals that utilize hospitalists compared with those that do not, which could further confound the relationship between the presence of hospitalists and adherence to quality measures.
Finally, this study only evaluated hospital-level performance, and it cannot offer insight on the quality of individual patient care by hospitalist providers.
Bottom line: The presence of hospitalists is associated with improvement in adherence to quality measures for both AMI and pneumonia, and across clinical domains of treatment and counseling.
Citation: López L, Hicks LS, Cohen AP, McKean S, Weissman JS. Hospitalists and the quality of care in hospitals. Arch Intern Med. 2009;169(15):1389-1394. TH
PEDIATRIC HM LITerature
Inpatient Curriculum Implicit, but Aligns with ACGME Competencies
By Mark Shen, MD
Clinical question: Does implicit resident learning on an inpatient unit correspond to the explicit Accreditation Council for Graduate Medical Education (ACGME) competencies?
Background: The ACGME competency-based model of education places an emphasis on task-oriented ability as a translation of skills and knowledge. Although it is recognized that most learning occurs through the process of daily patient care, it is unclear how much learning is explicit and linked to ACGME competencies, as defined in the goals and objectives of an inpatient rotation.
Study design: Qualitative, ethnographic case study.
Setting: One general pediatric floor in a large, urban pediatric hospital.
Synopsis: Over an eight-month period, one researcher directly observed and asked questions of inpatient teams as they worked on a general pediatric service. There was a particular emphasis on morning rounds. Data coding was completed in an iterative manner, and both data and method triangulation were used to enhance trustworthiness.
Curricular convergence occurred and was most obvious in the patient-care domain; however, the explicit curriculum was not formally referred to during the study period. The implicit curriculum was ill-structured and unpredictable, typically dictated by the patients’ socioclinical environment.
The primary limitations of this work are the focus on one service on one hospital floor, and that the study authors were former trainees or employees of that institution. This institution-specific bias, however, might be gauged by the degree to which the themes in this research will resonate with clinician-educators who read this article. Given the increasing time constraints on explicit inpatient didactic teaching, the vignettes and conclusions within this report are likely to find many a sympathetic ear. Illumination of the hidden curriculum could further support learner-centered education.
Bottom line: The inpatient service is a fertile and primarily implicit training ground for the ACGME competencies.
Citation: Balmer DF, Master CL, Richards B, Giardino AP. Implicit versus explicit curricula in general pediatrics education: is there a convergence? Pediatrics. 2009;124(2):e347-354.
