Background: Observation units have been used to decrease unnecessary inpatient admissions, which have improved cost and resource utilization as well as overall patient satisfaction (1). As a result, 42% (and growing) of hospitals nationally now utilize observation units, with a sizable amount directed by hospitalists (2). Despite their growth and advantages, observation units are not typical rotation sites for students, and there is a paucity of published literature regarding students rotating on the observation unit.
Purpose: We hypothesized that time spent on the observation unit (in addition to the general wards) can meaningfully add to a student’s clerkship experience. We developed an internal medicine inpatient clerkship curriculum for physician assistant (PA) students that included time in our hospitalist-run observation unit. At the end of their rotation, we gathered qualitative feedback from students to assess how valuable their experience was. We felt that PA students would benefit greatly from the observation unit since, at our institution’s observation unit, advanced practice providers (APP) work daily alongside our hospitalist physicians. Nonetheless, our PA student clerkship’s objectives, structure, and level of learning mirror the traditional medical student clerkship, and as such, we suggest that the qualitative results we present below are applicable both to PA and medical students.
Description: We designed this six-week clerkship to include one week in the observation unit with the other weeks rotating on the medicine wards and the admitting service. Students followed two to four patients each day with a hospitalist preceptor (physician or APP) in a fashion like that on the wards. Eight of nine total students positively rated the observation unit in comparison to the wards, highlighting the fast-paced environment with frequent discharges, better understanding of post-procedure monitoring, exposure to medically simpler cases, and more opportunities to practice a greater number and variety of physical exam skills with the higher turnover of patients. Students shared that the simpler cases and repetitive practice of coordinating discharges provided more autonomy to make clinical decisions independently, particularly with less consultant input. The one student with unfavorable feedback shared that the high patient census with a quick turn-around time created a rushed, stressful environment with pressure to discharge patients. However, some students also felt that the high turnover rate of patients enhanced their understanding of admission versus discharge reasoning. One shared, “It was helpful to understand why these patients did not need a full admission but still need to be observed. It helped me understand some of the gray area between discharge and admit.” Of note, all students passed their end-of-rotation exam.
Conclusions: The observation unit may be an area of the hospital where its educational value for students is underutilized. In our experience, students found more autonomy to make medical decisions and to participate in discharge planning. Given the prevalence of observation status among hospitals, a clerkship curriculum incorporating one or two weeks in observation units can be beneficial to students looking for careers in either academic or community settings.
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