Ratelle, John T.

Abstract Background Hospitalists work in complex clinical environments with rising patient acuity and competing demands. Uncertainty is an inescapable part of this work, yet little is known about how hospitalists experience and manage clinical uncertainty. Objectives To explore how hospitalists experience and manage uncertainty in clinical practice. Methods We conducted a single‐center qualitative study using reflexive thematic analysis within a constructivist paradigm. We interviewed hospitalist attending physicians during and/or after their work week and analyzed data inductively, drawing on literature about uncertainty in other clinical contexts. To strengthen rigor and trustworthiness, we held return‐of‐findings feedback sessions with participants. Results We interviewed 12 hospitalists between April 2023 and September 2024. Across diverse clinical situations, participants framed uncertainty through the lens of hospital discharge, using it as an anchor for decision‐making. Managing uncertainty required cognitive and emotional resources and was influenced by participants’ “bandwidth,” or perceived capacity to manage competing professional and personal demands. Perceived bandwidth shaped participants’ responses to uncertainty. Adequate bandwidth encouraged uncertainty engagement, while limited bandwidth prompted deferral or offloading. Participants described how they attempted to ease the burden of uncertainty for their oncoming colleagues by adjusting their documentation and care plans during handoffs. Conclusions Hospitalists experience uncertainty as a routine part of clinical practice and manage it pragmatically to advance patients toward discharge. Their approaches are shaped by their perceived bandwidth. The influences of uncertainty should be considered when assessing workload, organizing clinical service, and planning handoffs.

Teamwork in graduate medical education (GME) is often hindered in clinical learning environments where discontinuity among residents, supervisors, and other health care professionals is typical. Teaming is a conceptual approach to teamwork in dynamic environments with constantly changing team members and goals. Teaming is built on principles of project management and team leadership, which together provide an attractive strategy for addressing teamwork challenges in GME. Indeed, teaming is now a requirement of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program. However, many clinician-educators and leaders may be unfamiliar with teaming and how to integrate it into their GME programs. In this article, the teaming framework is described with a specific example of how it can be applied to improve hospital ward rounds, a common setting of teamwork breakdown. The goal of this article is to educate and encourage GME leaders as they learn new ways to implement teaming to improve patient care and education in their programs.

AbstractBackgroundMany hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.ObjectiveTo measure the correlation between patient‐clinician care agreement and discharge outcomes.DesignA prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).Setting and ParticipantsInternal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019‐March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.Main Outcome and MeasuresPatient–clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30‐day readmission was measured. Then, associations between patient‐clinician agreement, delayed discharge, and 30‐day readmissions were analyzed using multivariable logistic regression.ResultsOf the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient–clinician agreement scores were not significantly correlated with discharge outcomes. Patient–clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home‐goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).ConclusionsPatients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.

Hospital medicine ward rounds are often conducted away from patients’ bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between “time-at-bedside,” patient experience, and patient–clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient’s care inside versus outside the patient’s room. “Time-at-bedside” was defined as the proportion of time spent discussing a patient’s care in his or her room. Patient experience and patient–clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient’s main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience ( P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience.

Abstract Context Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. Methods Using constructivist grounded theory, we conducted 23 semi‐structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de‐identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. Results Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making ‘real decisions’ for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. Conclusions This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Purpose Successful training of internal medicine (IM) residents requires accurate assessments. Patients could assess IM residents in a hospital setting, but medical educators must understand how contextual factors may affect assessments. The objective was to investigate relationships between patient, resident, and hospital-encounter characteristics and the results of patient assessments of IM resident professionalism. Method The authors performed a prospective cohort study of postgraduate year 1 (PGY-1) IM residents and their patients at 4 general medicine inpatient teaching services at Mayo Clinic Hospital–Rochester, Saint Marys Campus in Rochester, Minnesota, from July 1, 2015, through June 30, 2016. Patient assessments of resident professionalism were adapted from validated instruments. Multivariable modeling with generalized estimating equations was used to determine associations between patient assessment scores and characteristics of residents, residents’ clinical performance and evaluations (including professionalism assessments in other settings), patients, and hospital encounters and to account for repeated assessments of residents. Results A total of 409 patients assessed 72 PGY-1 residents (mean [SD], 5.7 [3.0] patient assessments per resident). In the multivariable model, only the highest rating out of 5 levels for overall satisfaction with hospital stay was significantly associated with patient assessment scores of resident professionalism (β [SE], 0.80 [0.08]; P < .001). Hospitalized patients’ assessment scores of resident professionalism were not significantly correlated with assessment scores of resident professionalism in other clinical settings. Conclusions Hospitalized patients’ assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment.