Dr. Anjala V. Tess, a hospitalist at the Beth Israel Deaconess Medical Center in Boston, spends about 70% of her time teaching about quality improvement and patient safety. She’s the director of quality and safety for graduate medical education at BIDMC and she helped create the Stoneman Elective on Quality Improvement, which serves as a sort of mandatory patient safety boot camp for residents.

But Dr. Tess also wanted her residents to understand how hospital medicine practices are run, from where the money comes from to how the schedules get made. So about a decade ago, she started teaching the hospital medicine elective, a 2- to 3-week course that covers the history of hospital medicine, the different practice models, how hospitals and hospitalists get paid, and the literature on quality improvement. The 10 residents who complete the course each year visit other hospitals to see how various hospital medicine practices are run.

In an interview, Dr. Tess explained why she started the course at BIDMC and how it has changed over time.

Question: How did the hospital medicine elective get started?

Dr. Tess: One day, I found myself as a member of a practice and all of a sudden I was learning about billing and hearing about how budgets were "neutral" or "positive" or "negative." I had no idea what any of that meant. At the same time, we had more and more residents coming through [internal medicine training] who were interested in hospital medicine as a whole. So I got permission to pull together an elective that was broadly titled, "the Hospital Medicine Elective." Residents, as it is, spend a lot of time in the inpatient setting, so putting together another clinical elective wouldn’t necessarily augment their learning. I decided to try to teach them a little bit about the practice of hospital medicine because the field is much more than just inpatient medicine.

Question: Residents must complete a project as part of the elective. What do they work on?

Dr. Tess: The residents are divided into two groups and I give them a fictional case – a hospital medicine group that’s been established for about 4-5 years, but it’s a mess. It’s falling apart and they can’t keep providers on staff. The hospital is upset, and the nursing staff feels like the hospitalists aren’t engaged anymore. I give the residents information on the current census, billings, and salaries. At the end of the rotation, the two groups make a pitch to redesign the program. It brings the tutorials and readings to life because they have to understand the concept of bringing value as a hospitalist. The presentations usually come down to who makes the best value argument and who can come up with the most innovative way to bring value from this new group to the hospital.

Question: What surprises the residents as they go through the course?

Dr. Tess: For most of them, they are surprised by the layers of bureaucracy around payment and how complicated it is to build a budget. They always tell me that the hardest part is building the schedule. They’re asked to take care of 50 patients a day and when they try to staff the service with a limited number of physicians, they realize that it is very challenging to do that and still come up with a job description that someone would be willing to take.

Question: Is this type of course an essential part of preparing to be a hospitalist?

Dr. Tess: I think it is mission critical for everybody to see patients well and safely on graduation. The clinical training that residents receive is more important, but I do think that this type of elective helps the newer graduates understand what they are getting into. It also helps people when they are applying for jobs. They are able to ask much more appropriate questions. I’ve heard anecdotally from some of the local folks who interview our residents that the ones who went through the hospital medicine elective ask questions that demonstrate a better understanding of what it’s like to be in a hospital medicine practice. They are no longer thinking about just themselves and their job, but about themselves as a member of a practice.

Question: How have you changed the course over the years?

Dr. Tess: One of the major changes that I made was changing the case. We went from cases trying to establish hospital medicine programs to trying to fix a troubled program. In the last 5 or 6 years, I’ve changed the slant on it so that the hospital isn’t happy with some of the quality metrics. In the past, I’ve used catheter-associated urinary tract infections or the poor deep vein thrombosis compliance rates. Lately, I’ve used readmissions because they are a little more topical. And as the role of hospitalists in partnering with primary care providers around Accountable Care Organizations gets sorted out, for example, I need to start to bring that into the cases as well.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to mschneider@frontlinemedcom.com.

Preparing residents for the real world of hospital medicine