Background: Observation services continue are a growing part of U.S. healthcare, with over 90% of surveyed hospitalist groups providing observation care. Despite observation services growing at teaching hospitals, few residents receive structured training in this area.
Purpose: To create a structured clinical experience for internal medicine residents that gives an initial introduction to observation medicine delivery and organization.
Description: Since July 2013, our institution has had an embedded observation medicine experience coupled with a high intensity ambulatory rotation as part of an overall internal medicine resident transition of care rotation. The rotation curriculum meets the ACGME milestones in several key areas. PGY-3 residents experience hospitalist practice in a dedicated observation unit, managing common observation clinical conditions such as chest pain, congestive heart failure, respiratory disease, syncope, and abdominal pain. In addition, residents further enhance their own clinical reasoning skills in the care of observation patients with a focus on heightening awareness of determining patients that require short term observation, clinical decision pathways associated with diagnosis/treatment of these patients, and evidence supporting high value care. Residents develop patient-centered skills as part of a multidisciplinary team that is consistent with hospital medicine practice. As part of this team, residents develop improved interpersonal and communication skills with patients, team members and referring physicians. Finally, residents broaden and apply skills in system-based accountable care, resource utilization, and care variation. Similar to preceptorship in the clinic ambulatory setting, residents have close mentorship and supervision by hospital medicine faculty with a goal of helping them achieve understanding of basic observation principles. In addition to experiential learning, residents gain knowledge on observation principles through structured didactics in several key observation diagnoses. Evaluation of the resident focuses on these goals. Resident feedback supports the exposure to observation medicine as part of the residency training especially high value methods of evaluating lower risk chest pain and syncope. Residents felt that instruction in the observation unit was helpful in understanding patient triage from the emergency department and in transition of care of less acute patients that would normally go to the inpatient setting. Interest in this rotation has been expressed by residents in other training programs such as emergency medicine, providing the framework for a multispecialty learner rotation.
Conclusions: Although these skills may be foreign to internal medicine residents, integration of observation medicine instruction into internal medicine residency training is an important part of preparing internists for eventual practice in the changing healthcare marketplace.