Background:
As of July 2010, there were more than 30,000 hospitalists in the United States. The quality of care rendered by hospitalists is not uniform. Although patient satisfaction metrics like Press Ganey attempt to measure service excellence, no empiric research has been performed to characterize or define clinical excellence in hospital medicine.
Methods:
The Chiefs of Hospital Medicine at five different hospitals were emailed and asked to identify the “clinically excellent” hospitalists within their groups. The named hospitalists were invited to participate in the study; those agreeable would be shadowed during routine clinical care of patients. A data extraction sheet was developed and pilot tested to focus the observer’s attention on elements believed to be associated with clinical excellence. Detailed field notes, both quantitative and qualitative, were collected during the observation.
Results:
A total of 26 hospitalists were shadowed as they took care of patients. The average age of the physicians was 38 years and their average experience in hospital medicine was 6 years. Each hospitalist was observed for an average of 5 hours and they were observed with a mean of 7 patients (total number of patient encounters observed = 197). On average, the physicians spent 11 minutes with each patient; patients were examined for a mean of 100 seconds. In terms of balance of dialogue, these respected providers spoke on average 71% of the time during the discourse. The frequency of certain select desirable behaviors observed were as follows: starting encounters with an “open ended” question (76%); integrating non‐medical conversation to connect with patient (30%); displaying empathy during the encounters (27%). Each encounter was given a global rating and 14% were judged to be “clinically excellent”. Several reasons that encounters were judged not to be “clinically excellent” were the lack of non‐medical conversation used to connect with patients (70% of the encounters), doctor neglected to wash hands prior to entering room (24% of the encounters), doctor did not uncover / disrobe the body part being examined (39%), and failing to ask permission prior to examining the patient (36%).
Conclusions:
This study represents a first step in trying to characterize clinical excellence in Hospital Medicine, using both qualitative and quantitative data. Because hospitalists spend only a small amount of time with patients, relative to the time spent in indirect patient care, it is imperative that we make the most of this caring time and strive for clinical excellence consistently during every encounter.