Nancy M. Kaufman, M.D.
Traditionally, the teaching of pediatrics has taken place in the inpatient setting. In most medical schools half or more of the clerkship experience is inpatient based. With the increased emphasis on teaching primary care pediatrics, particularly in the ambulatory setting, some might assume that the hospital has become an outdated site for teaching pediatrics. This is far from true, as the wards and the newborn nursery remain important sites, with many advantages for teaching medical students. Clerkship directors need to recognize the vast clinical resources available for teaching students in the inpatient setting, and to look for ways to incorporate more of the generalist and primary care curriculum into the experience.
Inpatient sites currently used for teaching medical students include wards in a variety of hospital settings including university, community and children's hospitals. The patients on a ward may be limited by their age, the type of illness or whether the problems are medical or surgical in nature. Some students have an opportunity to work in the newborn nursery, the neonatal intensive care unit and the pediatric intensive care unit. As patient care becomes increasingly subspecialized and complex, opportunities for teaching principles of primary care diminish. It is easy for students and attendings alike to become caught up in the complexities of management.
Ideally, students should have early access to the patients, so that they may participate in major decisions regarding diagnosis and management. Patients with straightforward and uncomplicated problems are ideal for students. Spending time in the newborn nursery is preferable to time in the neonatal intensive care unit. Nevertheless there will be times when medical students will rotate through services involved in complex patient care. This places increased responsibility on the attending to identify issues related to primary care and to introduce them during teaching rounds. Examples include, discussion of the presentation of the illness and generation of a differential diagnosis at the time of presentation, discussion of relevant health supervision issues, and discussion of the impact of the illness upon the patient's family.
There are numerous advantages to teaching medical students in the inpatient setting. The student has more time with the patient and generally with the caregiver. This provides opportunities to go back and repeat the physical examination or fill in items which were left out of the history and physical examination. It also provides an excellent opportunity for housestaff and attendings to demonstrate abnormal physical findings. Since the patients are there for a longer period of time, several students may be gathered to go on physical diagnosis rounds. The inpatient setting also provides an opportunity to observe the evolution of an illness or physical findings over time. It further gives the student an opportunity to observe the response to treatment.
The attending on the inpatient service may have the luxury of spending a greater amount of time teaching about each patient than is available in the outpatient setting, where there may be more pressure to move on to the next patient. Students benefit from the continuity of working with the same housestaff and faculty over a prolonged period of time. Students learn to appreciate the role of the physician in the health care team, learning how to interact with consultants, social workers, nurses and other health care workers.
Through frequent repeated contact with the patient and family, the student has the opportunity to more fully appreciate the emotional impact of illness on the child and family. The student learns to appreciate the physician's role in comforting, supporting and educating the patient and family.
Caring for patients in the inpatient setting often provides the student with the opportunity to learn to manage complex or multiple problems simultaneously. This includes learning how to manage the data from a variety of diagnostic tests and procedures as well as to see how the treatment of one problem may have an impact upon another problem. Through the care of complex patients, students have the opportunity to become experts on a particular illness. They can use this knowledge to educate their fellow students and the housestaff. In addition, they can identify management issues and questions which can be studied and evaluated through reading, literature searches and discussions with consultants. Through these actions and interactions, the student learns to critically evaluate information from multiple resources and begins to develop clinical judgment.
While the advantages of teaching in the inpatient setting are significant, there are also disadvantages which must be recognized in order to minimize their effects on the student's overall education. The selection of patients encountered in the inpatient setting is biased towards those with unusual or complicated medical problems. There is a tendency for the student to develop a skewed impression of a particular disease. For example, if the student's only exposure to asthmatics is on the inpatient ward, he/she will leave pediatrics with the impression that asthma is a severe life-threatening illness requiring extensive emergency intervention. He/she will miss the opportunity to learn how to manage this very common chronic illness in the outpatient setting.
Other disadvantages to consider are that frequently the diagnosis has been made before the student sees the patient for the initial history and physical examination. The student may be the last in a succession of housestaff and attendings to see the patient, resulting in a fatigued and uncooperative patient and parent. The experience of caring for a child in the hospital provides limited opportunity to teach a family or community-oriented approach to patient care. The population of patients encountered on an inpatient service is changing, with fewer common acute problems and more intensive care patients. In addition, patients tend to stay in the hospital for a shorter duration, with completion of care at home, sometimes with home health visits. Fewer surgical patients are seen preoperatively.
Teaching in the inpatient setting often focuses on management issues which are beyond the level of medical student understanding. Attendings are often subspecialists who feel most comfortable discussing the details of their area of expertise. There is a tendency to accept the given diagnosis, eliminating opportunities for discussion of differential diagnosis and initial diagnostic management.
The clerkship director needs to develop strategies to overcome the disadvantages inherent in teaching in the inpatient setting and to enhance the available rich academic advantages. One of the first steps a clerkship director can take is to identify a curriculum of generalist and primary care content. The student must have this curriculum and know what is expected of him/her in terms of knowledge and competencies. In addition, ward attendings and housestaff should be familiar with the curriculum and should be given ideas for how to implement it.
Attendings can redirect their efforts during attending rounds. Greater emphasis can be placed upon the process of problem solving. Rather than discussing detailed issues of management, the attending could focus the discussion during rounds on the differential diagnosis of the presenting complaint and the rationale behind the initial diagnostic work-up. Issues of primary care can be identified in each patient and brought into the discussion. Examples include the assessment of the child's growth and development, nutrition, and immunization status. Rounds can become more patient-centered. The impact of the illness on the child and the family can be discussed. The attendings should point out the rarity of conditions encountered in the hospital, emphasizing the prevalence of less severe conditions in the general population. In general, hospitalized patients receive extensive work-ups, with numerous laboratory tests and diagnostic procedures. The role of a more limited work-up combined with observation or outpatient treatment should be emphasized in appropriate cases.
Attending physicians serve as important role models to the housestaff and medical students. Their method of communicating with patients, families, referring physicians, nursing staff and housestaff become important examples for the students.
The inpatient setting provides an important opportunity for the attending physician to observe the student in his/her interaction with the patient in performing a history and physical examination. These observations can be used both to instruct the student and to evaluate competency.
Good attendings often develop standardized cases which can be used to supplement the cases available on the ward, giving the students a more balanced exposure to pediatrics.
The ward attending can teach the students critical appraisal skills which will be useful in establishing a pattern of lifelong continuous learning. This might involve requiring the student to perform literature searches combined with critical review of the articles obtained. Students should first be able to identify precisely problems in their patient which need further research. They should be allowed opportunities to research these questions and present the information from their reviews during rounds. Understanding the elements and process of decision making is far more important to the professional development of the future physician than is the acquisition of medical facts. The skills of identifying a problem, seeking further information through consultation and literature review, and critically evaluating the information are tasks that can be performed on any patient available for teaching. Recognizing that it is the process of problem solving more than learning about specific illnesses, which is the educational goal of the student, will help the ward attending optimize the use of all patients available for teaching purposes.
In summary, the goal of teaching in the inpatient setting is to develop problem-solving skills and approach to patient care rather than to teach isolated facts about the limited number of illnesses which may be encountered. While the attending may feel pressure to provide the most-up-to date or state-of-the art information regarding the management of a particular problem, especially if it is in his field of interest, this knowledge may be of limited use to the medical student. The attending instead needs to redirect efforts to focus discussion of the differential diagnosis of the presenting complaint and the common, less severe presentation of the illness. The attending needs to stress the importance of remaining open-minded to other diagnoses and not focusing too early on what appears to be an obvious diagnosis. Primary care issues can be introduced into the discussion of even complicated hospitalized patients. A patient-centered approach rather than an illness-centered approach will enable the student to identify important psycho-social and practical needs of the patient, as well as learn about the details of medical management.
The implementation of change requires the development of a curriculum with clearly stated goals and objectives. The curriculum must be made available to those who teach as well as to those who learn. The role of the housestaff as teachers must be emphasized and they should be trained to be effective teachers. The clerkship director must be given the time and resources to train faculty teachers and evaluate their effectiveness. Good teachers need to be rewarded, with time made available for teaching. This includes freeing them from other clinical responsibilities while attending. With additional time devoted to teaching, the attendings should be expected to observe the student in his/her interactions with patients and families. The attending should be able to review the student's efforts in literature searches and reviews.
In addition to being given time to teach, faculty need to develop effective teaching skills. Educational consultants both within the medical school and from visiting institutions, combined with faculty development workshops, should be available to enhance the effectiveness of faculty as attendings.
The hospital is likely to remain a vital, dynamic site for the education of medical students. If the clerkship director is aware of the unique resources available in the inpatient setting and can maximize them through the enhancement of attending and housestaff teaching skills, the goals of the curriculum can be met no matter what type of patients are seen. The comprehensive approach to patient care which occurs in the inpatient setting complements the limited and at times focused approach which the students learn in the ambulatory setting.