Haruka Torok, MD, MSc

Patient satisfaction scores are being reported publicly and will affect hospital reimbursement rates under Hospital Value Based Purchasing.[1] Patient satisfaction scores are currently obtained through metrics such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)[2] and Press Ganey (PG)[3] surveys. Such surveys are mailed to a variable proportion of patients following their discharge from the hospital, and ask patients about the quality of care they received during their admission. Domains assessed regarding the patients' inpatient experiences range from room cleanliness to the amount of time the physician spent with them.

The Society of Hospital Medicine (SHM), the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] Ideally, accurate information would be delivered as feedback to individual providers in a timely manner in hopes of improving performance; however, the current methodology has shortcomings that limit its usefulness. First, several hospitalists and consultants may be involved in the care of 1 patient during the hospital stay, but the score can only be tied to a single physician. Current survey methods attribute all responses to that particular doctor, usually the attending of record, although patients may very well be thinking of other physicians when responding to questions. Second, only a few questions on the surveys ask about doctors' performance. Aforementioned surveys have 3 to 8 questions about doctors' care, which limits the ability to assess physician performance comprehensively. Finally, the surveys are mailed approximately 1 week after the patient's discharge, usually without a name or photograph of the physician to facilitate patient/caregiver recall. This time lag and lack of information to prompt patient recall likely lead to impreciseness in assessment. In addition, the response rates to these surveys are typically low, around 25% (personal oral communication with our division's service excellence stakeholder Dr. L.P. in September 2013). These deficiencies limit the usefulness of such data in coaching individual providers about their performance because they cannot be delivered in a timely fashion, and the reliability of the attribution is suspect.

With these considerations in mind, we developed and validated a new survey metric, the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH). We hypothesized that the results would be different from those collected using conventional methodologies.

PATIENTS AND METHODS

RESULTS

A total of 330 patients were considered to be eligible through medical record screening. Of those patients, 73 (22%) were already discharged by the time the research assistant attempted to enroll them after 2 days of care by a single physician. Of 257 inpatients approached, 30 patients (12%) refused to participate. Among the 227 consented patients, 24 (9%) were excluded as they were unable to correctly identify their hospitalist provider. A total of 203 patients were enrolled, and each patient rated a single hospitalist; a total of 29 unique hospitalists were assessed by these patients. The patients' mean age was 60 years, 114 (56%) were female, and 61 (30%) were of nonwhite race (Table 1). The hospitalist physicians' demographic information is also shown in Table 1. Two hospitalists with fewer than 4 surveys collected were excluded from the analysis. Thus, final analysis included 200 unique patients assessing 1 of the 27 hospitalists (mean=7.4 surveys per hospitalist).

DISCUSSION

Our new metric, TAISCH, was found to be a reliable and valid measurement tool to assess patient satisfaction with the hospitalist physician's care. Because we only surveyed patients who could correctly identify their hospitalist physicians after interacting for at least 2 consecutive days, the attribution of the data to the individual hospitalist is almost certainly correct. The high participation rate indicates that the patients were not hesitant about rating their hospitalist provider's quality of care, even when asked while they were still in the hospital.

The majority of the patients approached were able to correctly identify their hospitalist provider. This rate (91%) was much higher than the rate previously reported in the literature where a picture card was used to improve provider recognition.[22] It is also likely that 1 physician, rather than a team of physicians, taking care of patients make it easier for patients to recall the name and recognize the face of their inpatient provider.

The CFA of TAISCH showed good fit but suggests that 2 variables, both from Kahn's etiquette‐based medicine (EtBM) checklist,[9] may not load in the same way as the other items. Tackett and colleagues reported that hospitalists who performed more EtBM behaviors scored higher on PG evaluations.[23] Such results, along with the comparable explanation of variance and reliability, convinced us to retain these 2 items in the final 15‐item TAISCH as dictated by the CFA. Although the literature supports the fact that physician etiquette is related to perception of high‐quality care, it is possible that these 2 questions were answered differently (and thereby failed to load the same way), because environmental limitations may be preventing physicians' ability to perform them consistently. We prefer the 15‐item version of TAISCH and future studies may provide additional information about its performance as compared to the 13‐item adaptation.

The significantly negative association between the Wong‐Baker pain scale and TAISCH stresses the importance of adequately addressing and treating the patient's pain. Hanna et al. showed that the patients' perceptions of pain control was associated with their overall satisfaction score measured by HCAHPS.[24] The association seen in our study was not unexpected, because TAISCH is administered while the patients are acutely ill in the hospital, when pain is likely more prevalent and severe than it is during the postdischarge settings (when the HCAHPS or PG surveys are administered). Interestingly, Hanna et al. discovered that the team's attention to controlling pain was more strongly correlated with overall satisfaction than was the actual pain control.[24] These data, now confirmed by our study, should serve to remind us that a hospitalist's concern and effort to relieve pain may augment patient satisfaction with the quality of care, even when eliminating the pain may be difficult or impossible.

TAISCH was found not to be correlated with PG scores. Several explanations for this deserve consideration. First, the postdischarge PG survey that is used for our institution does not list the name of the specific hospitalist providers for the patients to evaluate. Because patients encounter multiple physicians during their hospital stay (eg, emergency department physicians, hospitalist providers, consultants), it is possible that patients are not reflecting on the named doctor when assessing the the attending of record on the PG mailed questionnaire. Second, the representation of patients who responded to TAISCH and PG were different; almost all patients completed TAISCH as opposed to a small minority who decide to respond to the PG survey. Third, TAISCH measures the physicians' performance more comprehensively with a larger number of variables. Last, it is possible that we were underpowered to detect significant correlation, because there were only 24 providers who had data from both TAISCH and PG. However, our results endorse using caution in interpreting PG scores for individual hospitalist's performance, particularly for high‐stakes consequences (including the provision of incentives to high performer and the insistence on remediation for low performers).

Several limitations of this study should be considered. First, only hospitalist providers from a single division were assessed. This may limit the generalizability of our findings. Second, although patients were assured about confidentiality of their responses, they might have provided more favorable answers, because they may have felt uncomfortable rating their physician poorly. One review article of the measurement of healthcare satisfaction indicated that impersonal (mailed) methods result in more criticism and lower satisfaction than assessments made in person using interviews. As the trade‐off, the mailed surveys yield lower response rates that may introduce other forms of bias.[25] Even on the HCHAPS survey report for the same period from our institution, 78% of patients gave top box ratings for our doctors' communication skills, which is at the state average.[26] Similarly, a study that used postdischarge telephone interviews to collect patients' satisfaction with hospitalists' care quality reported an average score of 4.20 out of 5.[27] These findings confirm that highly skewed ratings are common for these types of surveys, irrespective of how or when the data are collected.

Despite the aforementioned limitations, TAISCH use need not be limited to hospitalist physicians. It may also be used to assess allied health professionals or trainees performance, which cannot be assessed by HCHAPS or PG. Applying TAISCH in different hospital settings (eg, emergency department or critical care units), assessing hospitalists' reactions to TAISCH, learning whether TAISCH leads to hospitalists' behavior changes or appraising whether performance can improve in response to coaching interventions for those performing poorly are all research questions that merit additional consideration.

CONCLUSION

TAISCH allows for obtaining patient satisfaction data that are highly attributable to specific hospitalist providers. The data collection method also permits high response rates so that input comes from almost all patients. The timeliness of the TAISCH assessments also makes it possible for real‐time service recovery, which is impossible with other commonly used metrics assessing patient satisfaction. Our next step will include testing the most effective way to provide feedback to providers and to coach these individuals so as to improve performance.

Patient satisfaction scores are being reported publicly and will affect hospital reimbursement rates under Hospital Value Based Purchasing.[1] Patient satisfaction scores are currently obtained through metrics such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)[2] and Press Ganey (PG)[3] surveys. Such surveys are mailed to a variable proportion of patients following their discharge from the hospital, and ask patients about the quality of care they received during their admission. Domains assessed regarding the patients' inpatient experiences range from room cleanliness to the amount of time the physician spent with them.

The Society of Hospital Medicine (SHM), the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] Ideally, accurate information would be delivered as feedback to individual providers in a timely manner in hopes of improving performance; however, the current methodology has shortcomings that limit its usefulness. First, several hospitalists and consultants may be involved in the care of 1 patient during the hospital stay, but the score can only be tied to a single physician. Current survey methods attribute all responses to that particular doctor, usually the attending of record, although patients may very well be thinking of other physicians when responding to questions. Second, only a few questions on the surveys ask about doctors' performance. Aforementioned surveys have 3 to 8 questions about doctors' care, which limits the ability to assess physician performance comprehensively. Finally, the surveys are mailed approximately 1 week after the patient's discharge, usually without a name or photograph of the physician to facilitate patient/caregiver recall. This time lag and lack of information to prompt patient recall likely lead to impreciseness in assessment. In addition, the response rates to these surveys are typically low, around 25% (personal oral communication with our division's service excellence stakeholder Dr. L.P. in September 2013). These deficiencies limit the usefulness of such data in coaching individual providers about their performance because they cannot be delivered in a timely fashion, and the reliability of the attribution is suspect.

With these considerations in mind, we developed and validated a new survey metric, the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH). We hypothesized that the results would be different from those collected using conventional methodologies.

PATIENTS AND METHODS

RESULTS

A total of 330 patients were considered to be eligible through medical record screening. Of those patients, 73 (22%) were already discharged by the time the research assistant attempted to enroll them after 2 days of care by a single physician. Of 257 inpatients approached, 30 patients (12%) refused to participate. Among the 227 consented patients, 24 (9%) were excluded as they were unable to correctly identify their hospitalist provider. A total of 203 patients were enrolled, and each patient rated a single hospitalist; a total of 29 unique hospitalists were assessed by these patients. The patients' mean age was 60 years, 114 (56%) were female, and 61 (30%) were of nonwhite race (Table 1). The hospitalist physicians' demographic information is also shown in Table 1. Two hospitalists with fewer than 4 surveys collected were excluded from the analysis. Thus, final analysis included 200 unique patients assessing 1 of the 27 hospitalists (mean=7.4 surveys per hospitalist).

DISCUSSION

Our new metric, TAISCH, was found to be a reliable and valid measurement tool to assess patient satisfaction with the hospitalist physician's care. Because we only surveyed patients who could correctly identify their hospitalist physicians after interacting for at least 2 consecutive days, the attribution of the data to the individual hospitalist is almost certainly correct. The high participation rate indicates that the patients were not hesitant about rating their hospitalist provider's quality of care, even when asked while they were still in the hospital.

The majority of the patients approached were able to correctly identify their hospitalist provider. This rate (91%) was much higher than the rate previously reported in the literature where a picture card was used to improve provider recognition.[22] It is also likely that 1 physician, rather than a team of physicians, taking care of patients make it easier for patients to recall the name and recognize the face of their inpatient provider.

The CFA of TAISCH showed good fit but suggests that 2 variables, both from Kahn's etiquette‐based medicine (EtBM) checklist,[9] may not load in the same way as the other items. Tackett and colleagues reported that hospitalists who performed more EtBM behaviors scored higher on PG evaluations.[23] Such results, along with the comparable explanation of variance and reliability, convinced us to retain these 2 items in the final 15‐item TAISCH as dictated by the CFA. Although the literature supports the fact that physician etiquette is related to perception of high‐quality care, it is possible that these 2 questions were answered differently (and thereby failed to load the same way), because environmental limitations may be preventing physicians' ability to perform them consistently. We prefer the 15‐item version of TAISCH and future studies may provide additional information about its performance as compared to the 13‐item adaptation.

The significantly negative association between the Wong‐Baker pain scale and TAISCH stresses the importance of adequately addressing and treating the patient's pain. Hanna et al. showed that the patients' perceptions of pain control was associated with their overall satisfaction score measured by HCAHPS.[24] The association seen in our study was not unexpected, because TAISCH is administered while the patients are acutely ill in the hospital, when pain is likely more prevalent and severe than it is during the postdischarge settings (when the HCAHPS or PG surveys are administered). Interestingly, Hanna et al. discovered that the team's attention to controlling pain was more strongly correlated with overall satisfaction than was the actual pain control.[24] These data, now confirmed by our study, should serve to remind us that a hospitalist's concern and effort to relieve pain may augment patient satisfaction with the quality of care, even when eliminating the pain may be difficult or impossible.

TAISCH was found not to be correlated with PG scores. Several explanations for this deserve consideration. First, the postdischarge PG survey that is used for our institution does not list the name of the specific hospitalist providers for the patients to evaluate. Because patients encounter multiple physicians during their hospital stay (eg, emergency department physicians, hospitalist providers, consultants), it is possible that patients are not reflecting on the named doctor when assessing the the attending of record on the PG mailed questionnaire. Second, the representation of patients who responded to TAISCH and PG were different; almost all patients completed TAISCH as opposed to a small minority who decide to respond to the PG survey. Third, TAISCH measures the physicians' performance more comprehensively with a larger number of variables. Last, it is possible that we were underpowered to detect significant correlation, because there were only 24 providers who had data from both TAISCH and PG. However, our results endorse using caution in interpreting PG scores for individual hospitalist's performance, particularly for high‐stakes consequences (including the provision of incentives to high performer and the insistence on remediation for low performers).

Several limitations of this study should be considered. First, only hospitalist providers from a single division were assessed. This may limit the generalizability of our findings. Second, although patients were assured about confidentiality of their responses, they might have provided more favorable answers, because they may have felt uncomfortable rating their physician poorly. One review article of the measurement of healthcare satisfaction indicated that impersonal (mailed) methods result in more criticism and lower satisfaction than assessments made in person using interviews. As the trade‐off, the mailed surveys yield lower response rates that may introduce other forms of bias.[25] Even on the HCHAPS survey report for the same period from our institution, 78% of patients gave top box ratings for our doctors' communication skills, which is at the state average.[26] Similarly, a study that used postdischarge telephone interviews to collect patients' satisfaction with hospitalists' care quality reported an average score of 4.20 out of 5.[27] These findings confirm that highly skewed ratings are common for these types of surveys, irrespective of how or when the data are collected.

Despite the aforementioned limitations, TAISCH use need not be limited to hospitalist physicians. It may also be used to assess allied health professionals or trainees performance, which cannot be assessed by HCHAPS or PG. Applying TAISCH in different hospital settings (eg, emergency department or critical care units), assessing hospitalists' reactions to TAISCH, learning whether TAISCH leads to hospitalists' behavior changes or appraising whether performance can improve in response to coaching interventions for those performing poorly are all research questions that merit additional consideration.

CONCLUSION

TAISCH allows for obtaining patient satisfaction data that are highly attributable to specific hospitalist providers. The data collection method also permits high response rates so that input comes from almost all patients. The timeliness of the TAISCH assessments also makes it possible for real‐time service recovery, which is impossible with other commonly used metrics assessing patient satisfaction. Our next step will include testing the most effective way to provide feedback to providers and to coach these individuals so as to improve performance.

Patient satisfaction scores are being reported publicly and will affect hospital reimbursement rates under Hospital Value Based Purchasing.[1] Patient satisfaction scores are currently obtained through metrics such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)[2] and Press Ganey (PG)[3] surveys. Such surveys are mailed to a variable proportion of patients following their discharge from the hospital, and ask patients about the quality of care they received during their admission. Domains assessed regarding the patients' inpatient experiences range from room cleanliness to the amount of time the physician spent with them.

The Society of Hospital Medicine (SHM), the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] Ideally, accurate information would be delivered as feedback to individual providers in a timely manner in hopes of improving performance; however, the current methodology has shortcomings that limit its usefulness. First, several hospitalists and consultants may be involved in the care of 1 patient during the hospital stay, but the score can only be tied to a single physician. Current survey methods attribute all responses to that particular doctor, usually the attending of record, although patients may very well be thinking of other physicians when responding to questions. Second, only a few questions on the surveys ask about doctors' performance. Aforementioned surveys have 3 to 8 questions about doctors' care, which limits the ability to assess physician performance comprehensively. Finally, the surveys are mailed approximately 1 week after the patient's discharge, usually without a name or photograph of the physician to facilitate patient/caregiver recall. This time lag and lack of information to prompt patient recall likely lead to impreciseness in assessment. In addition, the response rates to these surveys are typically low, around 25% (personal oral communication with our division's service excellence stakeholder Dr. L.P. in September 2013). These deficiencies limit the usefulness of such data in coaching individual providers about their performance because they cannot be delivered in a timely fashion, and the reliability of the attribution is suspect.

With these considerations in mind, we developed and validated a new survey metric, the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH). We hypothesized that the results would be different from those collected using conventional methodologies.

PATIENTS AND METHODS

RESULTS

A total of 330 patients were considered to be eligible through medical record screening. Of those patients, 73 (22%) were already discharged by the time the research assistant attempted to enroll them after 2 days of care by a single physician. Of 257 inpatients approached, 30 patients (12%) refused to participate. Among the 227 consented patients, 24 (9%) were excluded as they were unable to correctly identify their hospitalist provider. A total of 203 patients were enrolled, and each patient rated a single hospitalist; a total of 29 unique hospitalists were assessed by these patients. The patients' mean age was 60 years, 114 (56%) were female, and 61 (30%) were of nonwhite race (Table 1). The hospitalist physicians' demographic information is also shown in Table 1. Two hospitalists with fewer than 4 surveys collected were excluded from the analysis. Thus, final analysis included 200 unique patients assessing 1 of the 27 hospitalists (mean=7.4 surveys per hospitalist).

DISCUSSION

Our new metric, TAISCH, was found to be a reliable and valid measurement tool to assess patient satisfaction with the hospitalist physician's care. Because we only surveyed patients who could correctly identify their hospitalist physicians after interacting for at least 2 consecutive days, the attribution of the data to the individual hospitalist is almost certainly correct. The high participation rate indicates that the patients were not hesitant about rating their hospitalist provider's quality of care, even when asked while they were still in the hospital.

The majority of the patients approached were able to correctly identify their hospitalist provider. This rate (91%) was much higher than the rate previously reported in the literature where a picture card was used to improve provider recognition.[22] It is also likely that 1 physician, rather than a team of physicians, taking care of patients make it easier for patients to recall the name and recognize the face of their inpatient provider.

The CFA of TAISCH showed good fit but suggests that 2 variables, both from Kahn's etiquette‐based medicine (EtBM) checklist,[9] may not load in the same way as the other items. Tackett and colleagues reported that hospitalists who performed more EtBM behaviors scored higher on PG evaluations.[23] Such results, along with the comparable explanation of variance and reliability, convinced us to retain these 2 items in the final 15‐item TAISCH as dictated by the CFA. Although the literature supports the fact that physician etiquette is related to perception of high‐quality care, it is possible that these 2 questions were answered differently (and thereby failed to load the same way), because environmental limitations may be preventing physicians' ability to perform them consistently. We prefer the 15‐item version of TAISCH and future studies may provide additional information about its performance as compared to the 13‐item adaptation.

The significantly negative association between the Wong‐Baker pain scale and TAISCH stresses the importance of adequately addressing and treating the patient's pain. Hanna et al. showed that the patients' perceptions of pain control was associated with their overall satisfaction score measured by HCAHPS.[24] The association seen in our study was not unexpected, because TAISCH is administered while the patients are acutely ill in the hospital, when pain is likely more prevalent and severe than it is during the postdischarge settings (when the HCAHPS or PG surveys are administered). Interestingly, Hanna et al. discovered that the team's attention to controlling pain was more strongly correlated with overall satisfaction than was the actual pain control.[24] These data, now confirmed by our study, should serve to remind us that a hospitalist's concern and effort to relieve pain may augment patient satisfaction with the quality of care, even when eliminating the pain may be difficult or impossible.

TAISCH was found not to be correlated with PG scores. Several explanations for this deserve consideration. First, the postdischarge PG survey that is used for our institution does not list the name of the specific hospitalist providers for the patients to evaluate. Because patients encounter multiple physicians during their hospital stay (eg, emergency department physicians, hospitalist providers, consultants), it is possible that patients are not reflecting on the named doctor when assessing the the attending of record on the PG mailed questionnaire. Second, the representation of patients who responded to TAISCH and PG were different; almost all patients completed TAISCH as opposed to a small minority who decide to respond to the PG survey. Third, TAISCH measures the physicians' performance more comprehensively with a larger number of variables. Last, it is possible that we were underpowered to detect significant correlation, because there were only 24 providers who had data from both TAISCH and PG. However, our results endorse using caution in interpreting PG scores for individual hospitalist's performance, particularly for high‐stakes consequences (including the provision of incentives to high performer and the insistence on remediation for low performers).

Several limitations of this study should be considered. First, only hospitalist providers from a single division were assessed. This may limit the generalizability of our findings. Second, although patients were assured about confidentiality of their responses, they might have provided more favorable answers, because they may have felt uncomfortable rating their physician poorly. One review article of the measurement of healthcare satisfaction indicated that impersonal (mailed) methods result in more criticism and lower satisfaction than assessments made in person using interviews. As the trade‐off, the mailed surveys yield lower response rates that may introduce other forms of bias.[25] Even on the HCHAPS survey report for the same period from our institution, 78% of patients gave top box ratings for our doctors' communication skills, which is at the state average.[26] Similarly, a study that used postdischarge telephone interviews to collect patients' satisfaction with hospitalists' care quality reported an average score of 4.20 out of 5.[27] These findings confirm that highly skewed ratings are common for these types of surveys, irrespective of how or when the data are collected.

Despite the aforementioned limitations, TAISCH use need not be limited to hospitalist physicians. It may also be used to assess allied health professionals or trainees performance, which cannot be assessed by HCHAPS or PG. Applying TAISCH in different hospital settings (eg, emergency department or critical care units), assessing hospitalists' reactions to TAISCH, learning whether TAISCH leads to hospitalists' behavior changes or appraising whether performance can improve in response to coaching interventions for those performing poorly are all research questions that merit additional consideration.

CONCLUSION

TAISCH allows for obtaining patient satisfaction data that are highly attributable to specific hospitalist providers. The data collection method also permits high response rates so that input comes from almost all patients. The timeliness of the TAISCH assessments also makes it possible for real‐time service recovery, which is impossible with other commonly used metrics assessing patient satisfaction. Our next step will include testing the most effective way to provide feedback to providers and to coach these individuals so as to improve performance.

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.

Physician assistants (PA) have rapidly become an integral component in the United States health care delivery system, including in the field of Hospital Medicine, the fastest growing medical field in the United States.1, 2 Since its induction in 1997, hospitalist providers in North America have increased by 30‐fold.3 Correlating with this, the number of PAs practicing in the field of hospital medicine has also increased greatly in recent years. According to the American Academy of Physician Assistants (AAPA) census reports, Hospital Medicine first appeared as one of the specialty choices in the 2006 census (response rate, 33% of all individuals eligible to practice as PAs) when it was selected as the primary specialty by 239 PAs (1.1% of respondents). In the 2008 report (response rate, 35%), the number grew to 421 (1.7%) PAs.2

PA training programs emphasize primary care and offer limited exposure to inpatient medicine. After PA students complete their first 12 months of training in didactic coursework that teach the basic sciences, they typically spend the next year on clinical rotations, largely rooted in outpatient care.2, 4 Upon graduation, PAs do not have to pursue postgraduate training before beginning to practice in their preferred specialty areas. Thus, a majority of PAs going into specialty areas are trained on the job. This is not an exception in the field of hospital medicine.

In recent years, despite an increase in the number of PAs in Hospital Medicine, some medical centers have chosen to phase out the use of midlevel hospitalist providers (including PAs) with the purposeful decision to not hire new midlevel providers.5 The rationale for this strategy is that there is thought to be a steep learning curve that requires much time to overcome before these providers feel comfortable across the breadth of clinical cases. Before they become experienced and confident in caring for a highly complex heterogeneous patient population, they cannot operate autonomously and are not a cost‐effective alternative to physicians. The complexities associated with practicing in this field were clarified in 2006 when the Society of Hospital Medicine identified 51 core competencies in hospital medicine.3, 6 Some hospitalist programs are willing to provide their PAs with on‐the‐job training, but many programs do not have the educational expertise or the resources to make this happen. Structured and focused postgraduate training in hospital medicine seems like a reasonable solution to prepare newly graduating PAs that are interested in pursuing hospitalist careers, but such opportunities are very limited.7

To date, there is no available information about the learning needs of PAs working in hospital medicine settings. We hypothesized that understanding the learning needs of PA hospitalists would inform the development of more effective and efficient training programs. We studied PAs with experience working in hospital medicine to (1) identify self‐perceived gaps in their skills and knowledge upon starting their hospitalist careers and (2) understand their views about optimal training for careers in hospital medicine.

METHODS

RESULTS

Sixty‐nine PAs responded (response rate, 67%). Table 1 provides demographic characteristics of the respondents. The majority of respondents were 2635 years old and had worked as hospitalists for a mean of 4.3 years.

DISCUSSION

Our survey addresses a wide range of topics related to PA hospitalists' learning needs including their experience with the Core Competencies in Hospital Medicine and their views on the benefits of PA training following graduation. Although self‐efficacy is not assessed, our study revealed that PAs who are choosing hospitalist careers have limited prior clinical experience treating many medical conditions that are managed in inpatient settings, such as sepsis syndrome. This inexperience with commonly seen clinical conditions, such as sepsis, wherein following guidelines can both reduce costs and improve outcomes, is problematic. More experience and training with such conditions would almost certainly reduce variability, improve skills, and augment confidence. These observed variations in experience in caring for conditions that often prompt admission to the hospital among PAs starting their hospitalist careers emphasizes the need to be learner‐centered when training PAs, so as to provide tailored guidance and oversight.

Only a few other empiric research articles have focused on PA hospitalists. One article described a postgraduate training program for PAs in hospital medicine that was launched in 2008. The curriculum was developed based on the Core Competencies in Hospital Medicine, and the authors explained that after 12 months of training, their first graduate functioned at the level of a PA with 4 years of experience under her belt.7 Several articles describe experiences using midlevel providers (including PAs) in general surgery, primary care medicine, cardiology, emergency medicine, critical care, pediatrics, and hospital medicine settings.5, 820 Many of these articles reported favorable results showing that using midlevel providers was either superior or just as effective in terms of cost and quality measures to physician‐only models. Many of these papers alluded to the ways in which PAs have enabled graduate medical education training programs to comply with residents' duty‐hour restrictions. A recent analysis that compared outcomes related to inpatient care provided by a hospitalist‐PA model versus a traditional resident‐based model revealed a slightly longer length of stay on the PA team but similar charges, readmission rates, and mortality.19 Yet another paper revealed that patients admitted to a residents' service, compared with the nonteaching hospitalist service that uses PAs and nurse practitioners, were different, having higher comorbidity burdens and higher acuity diagnoses.20 The authors suggested that this variance might be explained by the difference in their training, abilities, and goals of the groups. There was no research article that sought to capture the perspectives of practicing hospitalist PAs.

Our study revealed that although half of respondents became hospitalists immediately after graduating from PA school, a majority agreed that additional clinical training in inpatient settings would have been welcomed and helpful. This study's results reveal that although there is a fair amount of perceived interest in postgraduate training programs in hospital medicine, there are very few training opportunities for PAs in hospital medicine.7, 21 The American Academy of Physician Assistants, the Society of Hospital Medicine, and the American Academy of Nurse Practitioners cosponsor Adult Hospital Medicine Boot Camp for PAs and nurse practitioners annually to facilitate knowledge acquisition, but this course is truly an orientation rather than a comprehensive training program.22 Our findings suggest that more rigorous and thorough training in hospital medicine would be valued and appreciated by PA hospitalists.

Several limitations of this study should be considered. First, our survey respondents may not represent the entire spectrum of practicing PA hospitalists. However, the demographic data of 421 PAs who indicated their specialty as hospital medicine in the 2008 National Physician Assistants Census Report were not dissimilar from our informants; 65% were women, and their mean number of years in hospital medicine was 3.9 years.2 Second, our study sample was small. It was difficult to identify a national sample of hospitalist PAs, and we had to resort to a creative use of social media to find a national sample. Third, the study relied exclusively on self‐report, and since we asked about their perceived learning needs when they started working as hospitalists, recall bias cannot be excluded. However, the questions addressing attitudes and beliefs can only be ascertained from the informants themselves. That said, the input from hospitalist physicians about training needs for the PAs who they are supervising would have strengthened the reliability of the data, but this was not possible given the sampling strategy that we elected to use. Finally, our survey instrument was developed based on the Core Competencies in Hospital Medicine, which is a blueprint to develop standardized curricula for teaching hospital medicine in medical school, postgraduate training programs (ie, residency, fellowship), and continuing medical education programs. It is not clear whether the same competencies should be expected of PA hospitalists who may have different job descriptions from physician hospitalists.

In conclusion, we present the first national data on self‐perceived learning needs of PAs working in hospital medicine settings. This study collates the perceptions of PAs working in hospital medicine and highlights the fact that training in PA school does not adequately prepare them to care for hospitalized patients. Hospitalist groups may use this study's findings to coach and instruct newly hired or inexperienced hospitalist PAs, particularly until postgraduate training opportunities become more prevalent. PA schools may consider the results of this study for modifying their curricula in hopes of emphasizing the clinical content that may be most relevant for a proportion of their graduates.