Molly Harrod, PhD

The demographic composition of physicians has shifted dramatically in the last five decades. The number of women matriculating into medical school rose from 6% in the 1960s¹ to 52% in 2019²; women accounted for 39% of full-time faculty in 2015.³ Despite this evolution of the physician gender array, many challenges remain.⁴ Women represented only 35% of all associate professors and 22% of full professors in 2015.³ Women experience gender-based discrimination, hostility, and unconscious bias as medical trainees^5-9 and as attending physicians^10-13 with significant deleterious effects including burnout and suicidal thoughts.¹⁴ While types of gender-based challenges are well described in the literature, strategies to navigate and respond to these challenges are less understood.

The approaches and techniques of exemplary teaching attending physicians (hereafter referred to as “attendings”) have previously been reported from groups of predominantly male attendings.^15-18 Because of gender-based challenges female physicians face that lead them to reduce their effort or leave the medical field,¹⁹ there is concern that prior scholarship in effective teaching may not adequately capture the approaches and techniques of female attendings. To our knowledge, no studies have specifically examined female attendings. Therefore, we sought to explore the lived experiences of six female attendings with particular emphasis on how they navigate and respond to gender-based challenges in clinical environments.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. We aimed to examine techniques, approaches, and attitudes of outstanding general medicine teaching attendings among groups previously not well represented (ie, women and self-identified underrepresented minorities [URMs] in medicine). URM was defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”²⁰ A modified snowball sampling approach²¹ was employed to identify attendings as delineated below.

To maintain quality while guaranteeing diversity in geography and population, potential institutions in which to observe attendings were determined by first creating the following lists: The top 20 hospitals in the U.S. News & World Report’s 2017-2018 Best Hospitals Honor Roll,²² top-rated institutions by Doximity in each geographic region and among rural training sites,²³ and four historically Black colleges and universities (HBCUs) with medical schools. Institutions visited during a previous similar study¹⁶ were excluded. Next, the list was narrowed to 25 by randomly selecting five in each main geographic region and five rural institutions. These were combined with all four HBCUs to create a final list of 29 institutions.

Next, division of hospital medicine chiefs (and/or general medicine chiefs) and internal medicine residency directors at each of these 29 institutions were asked to nominate exemplary attendings, particularly those who identified as women and URMs. Twelve attendings who were themselves observed in a previous study¹⁶ were also asked for nominations. Finally, recommendations were sought from leaders of relevant American Medical Association member groups.²⁴

Using this sampling method, 43 physicians were identified. An internet search was conducted to identify individual characteristics including medical education, training, clinical and research interests, and educational awards. These characteristics were considered and discussed by the research team. Preference was given to those attendings nominated by more than one individual (n = 3), those who had received teaching awards, and those with interests involving women in medicine. Research team members narrowed the list to seven attendings who were contacted via email and invited to participate. One did not respond, while six agreed to participate. The six attendings identified current team members who would be rounding on the visit date. Attendings were asked to recommend 6-10 former learners; we contacted these former learners and invited them to participate. Former learners were included to understand lasting effects from their attendings.

Data Collection

Observations

All 1-day site visits were conducted by two research team members, a physician (NH) and a qualitative research specialist (MQ). In four visits, an additional author accompanied the research team. In order to ensure consistency and diversity in perspectives, all authors attended at least one visit. These occurred between April 16 and August 28, 2018. Each visit began with direct observation of attendings (n = 6) and current learners (n = 24) during inpatient general medicine teaching rounds. Each researcher unobtrusively recorded their observations via handwritten, open field notes, paying particular attention to group interactions, teaching approach, conversations within and peripheral to the team, and patient–team interactions. After each visit, researchers met to compare and combine field notes.

Interviews and Focus Groups

Researchers then conducted individual, semistructured interviews with attendings and focus groups with current (n = 21) and former (n = 17) learners. Focus groups with learners varied in size from two to five participants. Former learners were occasionally not available for on-site focus groups and were interviewed separately by telephone after the visit. The interview guide for attendings (Appendix 1) was adapted from the prior study¹⁶ but expanded with questions related to experiences, challenges, and approaches of female and URM physicians. A separate guide was used to facilitate focus groups with learners (Appendix 1). Three current learners were unable to participate in focus groups due to clinical duties. All interviews and focus groups were audio recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a content analysis approach.²⁵ Inductive coding was used to identify codes derived from the data. Two team members (MQ and MH) independently coded the first transcript to develop a codebook, then met to compare and discuss codes. Codes and definitions were entered into the codebook. These team members continued coding five additional transcripts, meeting to compare codes, discussing any discrepancies until agreement was reached, adding new codes identified, and ensuring consistent code application. They reviewed prior transcripts and recoded if necessary. Once no new codes were identified, one team member coded the remaining transcripts. The same codebook was used to code field note documents using the same iterative process. After all qualitative data were coded and verified, they were entered into NVivo 10. Code reports were generated and reviewed by three team members to identify themes and check for coding consistency.

Role of the Funding Source

This study received no external funding.

We examined six exemplary attendings through direct observation of rounds and individual interviews. We also discussed these attendings with 21 current learners and 17 former learners (Appendix 2). All attendings self-identified as female. The group was diverse in terms of race/ethnicity, with three identifying as Black or African American, two as Asian, and one as White or Caucasian. Levels of experience as an attending ranged from 8 to 20 years (mean, 15.3 years). At the time of observation, two were professors and four were associate professors. The group included all three attendings who had been nominated by more than one individual, and all six had won multiple teaching awards. The observation sites represented several areas of the United States (Table 1).

The coded interview data and field notes were categorized into three broad overlapping themes based on strategies our attendings used to respond to gender-based challenges. The following sections describe types of challenges faced by female attendings along with specific strategies they employed to actively position themselves as physician team leaders, manage gender-based stereotypes and perceptions, and identify and embrace their unique qualities. Illustrative quotations or observations that further elucidate meaning are provided.

Female Attendings Actively Position Themselves as Physician Team Leaders

Our attendings frequently stated that they were assumed to be other healthcare provider types, such as nurses or physical therapists, and that these assumptions originated from patients, faculty, and staff (Table 2). Attending 3 commented, “I think every woman in this role has been mistaken for a different caretaker role, so lots of requests for nursing help. I’m sure I have taken more patients off of bed pans and brought more cups of water than maybe some of my male counterparts.” Some attendings responded to this challenge with the strategy of routinely wearing a white coat during rounds and patient encounters. This external visual cue was seen as a necessary reminder of the female attending role.

We found that patients and healthcare providers often believe teams are led by men, leading to a feeling of invisibility for female attendings. One current learner remarked, “If it was a new patient, more than likely, if we had a female attending, the patient’s eyes would always divert to the male physician.” This was not limited to patients. Attending 6 remembered comments from her consultants including, “‘Who is your attending? Let me talk with them,’ kind of assuming that I’m not the person making the decisions.” Female attendings would respond to this challenge by clearly introducing team members, including themselves, with roles and responsibilities. At times, this would require reintroductions and redirection if individuals still misidentified female team members.

Female attendings’ decision-making and thought processes were frequently second-guessed. This would often lead to power struggles with consultants, nurses, and learners. Attending 5 commented, “Even in residency, I felt this sometimes adversarial relationship with...female nurses where they would treat [female attendings] differently...questioning our decisions.” Female attendings would respond to this challenge by asserting themselves and demonstrating confidence with colleagues and at the bedside. This was an active process for women, as one former learner described: “[Female] attendings have to be a little bit more ‘on’—whatever ‘on’ is—more forceful, more direct....There is more slack given to a male attending.”

Female Attendings Consciously Work to Manage Gender-Based Stereotypes and Perceptions

Our attendings navigated gender-based stereotypes and perceptions, ranging from subtle microaggressions to overt sexual harassment (Table 3). This required balance between extremes of being perceived as “too nice” and “too aggressive,” each of which was associated with negativity. Attending 1 remarked, “I know that other [female] faculty struggle with that a bit, with being...assertive. They are assertive, and it’s interpreted [negatively].” Attending 6 described insidiously sexist comments from patients: “‘You are too young to be a physician, you are too pretty to be a physician.’ ‘Oh, the woman doctor...rather than just ‘doctor.’” During one observation of rounds, a patient remarked to the attending, “You have cold hands. You know, I’m going to have to warm those up.” Our attendings responded to these challenges by proactively avoiding characteristics and behaviors considered to be stereotypically feminine in order to draw attention to their qualities as physicians rather than as women. During interviews, some attendings directed conversation away from themselves and instead placed emphasis on coaching female learners to navigate their own demeanors, behaviors, and responses to gender bias and harassment. This would include intentional planning of how to carry oneself, as well as feedback and debrief sessions after instances of harassment.

Our attendings grappled with how to physically portray themselves to avoid gender-based stereotypes. Attending 6 said, “Sometimes you might be taken less seriously if you pay more attention to your makeup or jewelry.” The same attending recalled “times where people would say inappropriate things based on what I was wearing—and I know that doesn’t happen with my male colleagues.” Our attendings responded to this challenge through purposeful choices of attire, personal appearance, and even external facial expressions that would avoid drawing unwanted or negative personal attention outside of the attending role.

Female Attendings Intentionally Identify and Embrace Their Unique Qualities

Our attendings identified societal gender norms and “traditional” masculine expectations in medicine (Table 4). Attending 4 drew attention to her institution’s healthcare leaders by remarking, “I think that women in medicine have similar challenges as women in other professional fields....Well, I guess it is different in that the pictures on the wall behind me are all White men.” Female attendings responded to this challenge by eschewing stereotypical qualities and intentionally finding and exhibiting their own unique strengths (eg, teaching approaches, areas of expertise, communication styles). By embracing their unique strengths, attendings gained confidence and felt more comfortable as physicians and educators. Advice from Attending 3 for other female physicians encapsulated this strategy: “But if [medicine] is what you love doing, then find a style that works for you, even if it’s different....Embrace being different.”

Several attendings identified patterns of thought in themselves that caused them to doubt their accomplishments and have a persistent fear of being exposed as a fraud, commonly known as impostor syndrome. Attending 2 summarized this with, “I know it’s irrational a little bit, but part of me [asks], ‘Am I getting all these opportunities because I’m female, because I’m a minority?’” Our attendings responded by recognizing impostor syndrome and addressing it through repeated positive self-reinforcing thoughts and language and by “letting go” of the doubt. Attending 4 recalled her feelings after being announced as a teaching award recipient for the fourth year in a row: “It was just like something changed in me....Maybe you are a good attending. Maybe you are doing something that is resonating with a unique class of medical students year after year.”

Our interviews also revealed strategies used by female attendings to support and advance their own careers, as well as those of other female faculty, to address the effects of impostor syndrome. Our participants noted the important role of female mentors and sponsors. One former learner mentioned, “I think some of the administration, there are definitely females that are helping promote [the attending].” During an observation, Attending 1 indicated that she was part of a network of women and junior faculty forged to promote each other’s work since “some people are good at self-promotion and some are not.” This group shares accomplishments by distributing and publicizing their accolades.

This multisite, qualitative study informs the complex ways in which exemplary female teaching attendings must navigate being women in medicine. We identified myriad challenges female attendings face originating from patients, from healthcare workers, and within themselves. Our attendings relied upon the following key strategies to mitigate such challenges: (1) they actively position themselves as physician team leaders, (2) they consciously work to manage gender-based stereotypes and perceptions, and (3) they intentionally identify and embrace their unique qualities.

Prior scholarship surrounding gender-based challenges has focused primarily on strategies to improve healthcare systems for women. Much scrutiny has been placed on elevating institutional culture,^26-29 enacting clear policy surrounding sexual harassment,³⁰ ensuring women are actively recruited and retained,³¹ providing resources to assist in work-life balance,^26,32 and cultivating effective mentorship and social networks.^11,33,34

While our findings support the importance of improving healthcare systems, they are more congruent with recent scholarship on explicit personal tactics to mitigate gender-based challenges. Researchers have suggested physicians use algorithmic responses to patient-initiated sexual harassment,³⁵ advocate for those who experience harassment in real time,³⁶ and engage in dedicated practice responding to harassment.^37,38 Our results build on these studies by outlining strategies intended to navigate complex gender dynamics and role model approaches for learners. Interestingly, it was more common for attendings to discuss how they guide their learners and debrief after difficult situations than to discuss how they personally respond to gender-based harassment. While we are not certain why this occurred, three factors may have contributed. First, attendings mentioned that these conversations are often uncomfortable. Second, attendings appeared to accept a higher level of gender-based challenges than they would have tolerated for their learners. Lastly, although we did not gather demographic data from learners, several attendings voiced a strong desire to advocate for and equip female learners with strategies to address and navigate these challenges for themselves.

Gender stereotypes are ubiquitous and firmly rooted in long-standing belief patterns. Certain characteristics are considered masculine (eg, aggressiveness, confidence) and others feminine (eg, kindness, cooperation).¹⁰ Role congruity theory purports that stereotypes lead women to demonstrate behaviors that reflect socially accepted gender norms³⁹ and that social approval is at risk if they behave in ways discordant with these norms.^10,40 Our study provides perspectives from female physicians who walk the tightrope of forcefully asserting themselves more than their male counterparts while not being overly aggressive, since both approaches may have negative connotations.

This study has several limitations. First, it was conducted with a limited number of site visits, attendings, and learners. Likewise, attendings were internists with relatively advanced academic rank. This may reduce the study’s generalizability since attendings in other fields and at earlier career stages may utilize different strategies. However, we believe that if more senior-level female attendings experienced difficulties being recognized and legitimized in their roles, then one can assume that junior-level female faculty would experience these challenges even more so. Likewise, data saturation was not the goal of this exploratory study. Through intensive qualitative data collection, we sought to obtain an in-depth understanding of challenges and strategies. Second, many exemplary female attendings were overlooked by our selection methodology, particularly since women are often underrepresented in the factors we chose. The multisite design, modified snowball sampling, and purposeful randomized selection methodology were used to ensure quality and diversity. Third, attendings provided lists of their former learners, and thus, selection and recall biases may have been introduced since attendings may have more readily identified learners with whom they formed positive relationships. Finally, we cannot eliminate a potential Hawthorne effect on data collection. Researchers attempted to lessen this by standing apart from teams and remaining unobtrusive.

We identified strategies employed by exemplary female attendings to navigate gender-based challenges in their workplaces. We found that female attendings face unconscious bias, labels, power struggles, and harassment, simply because of their gender. They consciously and constantly navigate these challenges by positioning themselves to be seen and heard as team leaders, balancing aspects of their outward appearance and demeanor, embracing their differences and avoiding assimilation to masculine stereotypes of physician leaders, working to manage self-doubt, and coaching their female learners in these areas.

The authors are indebted to Suzanne Winter, MS, for assisting with coordination of study participants and site visits.

The demographic composition of physicians has shifted dramatically in the last five decades. The number of women matriculating into medical school rose from 6% in the 1960s¹ to 52% in 2019²; women accounted for 39% of full-time faculty in 2015.³ Despite this evolution of the physician gender array, many challenges remain.⁴ Women represented only 35% of all associate professors and 22% of full professors in 2015.³ Women experience gender-based discrimination, hostility, and unconscious bias as medical trainees^5-9 and as attending physicians^10-13 with significant deleterious effects including burnout and suicidal thoughts.¹⁴ While types of gender-based challenges are well described in the literature, strategies to navigate and respond to these challenges are less understood.

The approaches and techniques of exemplary teaching attending physicians (hereafter referred to as “attendings”) have previously been reported from groups of predominantly male attendings.^15-18 Because of gender-based challenges female physicians face that lead them to reduce their effort or leave the medical field,¹⁹ there is concern that prior scholarship in effective teaching may not adequately capture the approaches and techniques of female attendings. To our knowledge, no studies have specifically examined female attendings. Therefore, we sought to explore the lived experiences of six female attendings with particular emphasis on how they navigate and respond to gender-based challenges in clinical environments.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. We aimed to examine techniques, approaches, and attitudes of outstanding general medicine teaching attendings among groups previously not well represented (ie, women and self-identified underrepresented minorities [URMs] in medicine). URM was defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”²⁰ A modified snowball sampling approach²¹ was employed to identify attendings as delineated below.

To maintain quality while guaranteeing diversity in geography and population, potential institutions in which to observe attendings were determined by first creating the following lists: The top 20 hospitals in the U.S. News & World Report’s 2017-2018 Best Hospitals Honor Roll,²² top-rated institutions by Doximity in each geographic region and among rural training sites,²³ and four historically Black colleges and universities (HBCUs) with medical schools. Institutions visited during a previous similar study¹⁶ were excluded. Next, the list was narrowed to 25 by randomly selecting five in each main geographic region and five rural institutions. These were combined with all four HBCUs to create a final list of 29 institutions.

Next, division of hospital medicine chiefs (and/or general medicine chiefs) and internal medicine residency directors at each of these 29 institutions were asked to nominate exemplary attendings, particularly those who identified as women and URMs. Twelve attendings who were themselves observed in a previous study¹⁶ were also asked for nominations. Finally, recommendations were sought from leaders of relevant American Medical Association member groups.²⁴

Using this sampling method, 43 physicians were identified. An internet search was conducted to identify individual characteristics including medical education, training, clinical and research interests, and educational awards. These characteristics were considered and discussed by the research team. Preference was given to those attendings nominated by more than one individual (n = 3), those who had received teaching awards, and those with interests involving women in medicine. Research team members narrowed the list to seven attendings who were contacted via email and invited to participate. One did not respond, while six agreed to participate. The six attendings identified current team members who would be rounding on the visit date. Attendings were asked to recommend 6-10 former learners; we contacted these former learners and invited them to participate. Former learners were included to understand lasting effects from their attendings.

Data Collection

Observations

All 1-day site visits were conducted by two research team members, a physician (NH) and a qualitative research specialist (MQ). In four visits, an additional author accompanied the research team. In order to ensure consistency and diversity in perspectives, all authors attended at least one visit. These occurred between April 16 and August 28, 2018. Each visit began with direct observation of attendings (n = 6) and current learners (n = 24) during inpatient general medicine teaching rounds. Each researcher unobtrusively recorded their observations via handwritten, open field notes, paying particular attention to group interactions, teaching approach, conversations within and peripheral to the team, and patient–team interactions. After each visit, researchers met to compare and combine field notes.

Interviews and Focus Groups

Researchers then conducted individual, semistructured interviews with attendings and focus groups with current (n = 21) and former (n = 17) learners. Focus groups with learners varied in size from two to five participants. Former learners were occasionally not available for on-site focus groups and were interviewed separately by telephone after the visit. The interview guide for attendings (Appendix 1) was adapted from the prior study¹⁶ but expanded with questions related to experiences, challenges, and approaches of female and URM physicians. A separate guide was used to facilitate focus groups with learners (Appendix 1). Three current learners were unable to participate in focus groups due to clinical duties. All interviews and focus groups were audio recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a content analysis approach.²⁵ Inductive coding was used to identify codes derived from the data. Two team members (MQ and MH) independently coded the first transcript to develop a codebook, then met to compare and discuss codes. Codes and definitions were entered into the codebook. These team members continued coding five additional transcripts, meeting to compare codes, discussing any discrepancies until agreement was reached, adding new codes identified, and ensuring consistent code application. They reviewed prior transcripts and recoded if necessary. Once no new codes were identified, one team member coded the remaining transcripts. The same codebook was used to code field note documents using the same iterative process. After all qualitative data were coded and verified, they were entered into NVivo 10. Code reports were generated and reviewed by three team members to identify themes and check for coding consistency.

Role of the Funding Source

This study received no external funding.

We examined six exemplary attendings through direct observation of rounds and individual interviews. We also discussed these attendings with 21 current learners and 17 former learners (Appendix 2). All attendings self-identified as female. The group was diverse in terms of race/ethnicity, with three identifying as Black or African American, two as Asian, and one as White or Caucasian. Levels of experience as an attending ranged from 8 to 20 years (mean, 15.3 years). At the time of observation, two were professors and four were associate professors. The group included all three attendings who had been nominated by more than one individual, and all six had won multiple teaching awards. The observation sites represented several areas of the United States (Table 1).

The coded interview data and field notes were categorized into three broad overlapping themes based on strategies our attendings used to respond to gender-based challenges. The following sections describe types of challenges faced by female attendings along with specific strategies they employed to actively position themselves as physician team leaders, manage gender-based stereotypes and perceptions, and identify and embrace their unique qualities. Illustrative quotations or observations that further elucidate meaning are provided.

Female Attendings Actively Position Themselves as Physician Team Leaders

Our attendings frequently stated that they were assumed to be other healthcare provider types, such as nurses or physical therapists, and that these assumptions originated from patients, faculty, and staff (Table 2). Attending 3 commented, “I think every woman in this role has been mistaken for a different caretaker role, so lots of requests for nursing help. I’m sure I have taken more patients off of bed pans and brought more cups of water than maybe some of my male counterparts.” Some attendings responded to this challenge with the strategy of routinely wearing a white coat during rounds and patient encounters. This external visual cue was seen as a necessary reminder of the female attending role.

We found that patients and healthcare providers often believe teams are led by men, leading to a feeling of invisibility for female attendings. One current learner remarked, “If it was a new patient, more than likely, if we had a female attending, the patient’s eyes would always divert to the male physician.” This was not limited to patients. Attending 6 remembered comments from her consultants including, “‘Who is your attending? Let me talk with them,’ kind of assuming that I’m not the person making the decisions.” Female attendings would respond to this challenge by clearly introducing team members, including themselves, with roles and responsibilities. At times, this would require reintroductions and redirection if individuals still misidentified female team members.

Female attendings’ decision-making and thought processes were frequently second-guessed. This would often lead to power struggles with consultants, nurses, and learners. Attending 5 commented, “Even in residency, I felt this sometimes adversarial relationship with...female nurses where they would treat [female attendings] differently...questioning our decisions.” Female attendings would respond to this challenge by asserting themselves and demonstrating confidence with colleagues and at the bedside. This was an active process for women, as one former learner described: “[Female] attendings have to be a little bit more ‘on’—whatever ‘on’ is—more forceful, more direct....There is more slack given to a male attending.”

Female Attendings Consciously Work to Manage Gender-Based Stereotypes and Perceptions

Our attendings navigated gender-based stereotypes and perceptions, ranging from subtle microaggressions to overt sexual harassment (Table 3). This required balance between extremes of being perceived as “too nice” and “too aggressive,” each of which was associated with negativity. Attending 1 remarked, “I know that other [female] faculty struggle with that a bit, with being...assertive. They are assertive, and it’s interpreted [negatively].” Attending 6 described insidiously sexist comments from patients: “‘You are too young to be a physician, you are too pretty to be a physician.’ ‘Oh, the woman doctor...rather than just ‘doctor.’” During one observation of rounds, a patient remarked to the attending, “You have cold hands. You know, I’m going to have to warm those up.” Our attendings responded to these challenges by proactively avoiding characteristics and behaviors considered to be stereotypically feminine in order to draw attention to their qualities as physicians rather than as women. During interviews, some attendings directed conversation away from themselves and instead placed emphasis on coaching female learners to navigate their own demeanors, behaviors, and responses to gender bias and harassment. This would include intentional planning of how to carry oneself, as well as feedback and debrief sessions after instances of harassment.

Our attendings grappled with how to physically portray themselves to avoid gender-based stereotypes. Attending 6 said, “Sometimes you might be taken less seriously if you pay more attention to your makeup or jewelry.” The same attending recalled “times where people would say inappropriate things based on what I was wearing—and I know that doesn’t happen with my male colleagues.” Our attendings responded to this challenge through purposeful choices of attire, personal appearance, and even external facial expressions that would avoid drawing unwanted or negative personal attention outside of the attending role.

Female Attendings Intentionally Identify and Embrace Their Unique Qualities

Our attendings identified societal gender norms and “traditional” masculine expectations in medicine (Table 4). Attending 4 drew attention to her institution’s healthcare leaders by remarking, “I think that women in medicine have similar challenges as women in other professional fields....Well, I guess it is different in that the pictures on the wall behind me are all White men.” Female attendings responded to this challenge by eschewing stereotypical qualities and intentionally finding and exhibiting their own unique strengths (eg, teaching approaches, areas of expertise, communication styles). By embracing their unique strengths, attendings gained confidence and felt more comfortable as physicians and educators. Advice from Attending 3 for other female physicians encapsulated this strategy: “But if [medicine] is what you love doing, then find a style that works for you, even if it’s different....Embrace being different.”

Several attendings identified patterns of thought in themselves that caused them to doubt their accomplishments and have a persistent fear of being exposed as a fraud, commonly known as impostor syndrome. Attending 2 summarized this with, “I know it’s irrational a little bit, but part of me [asks], ‘Am I getting all these opportunities because I’m female, because I’m a minority?’” Our attendings responded by recognizing impostor syndrome and addressing it through repeated positive self-reinforcing thoughts and language and by “letting go” of the doubt. Attending 4 recalled her feelings after being announced as a teaching award recipient for the fourth year in a row: “It was just like something changed in me....Maybe you are a good attending. Maybe you are doing something that is resonating with a unique class of medical students year after year.”

Our interviews also revealed strategies used by female attendings to support and advance their own careers, as well as those of other female faculty, to address the effects of impostor syndrome. Our participants noted the important role of female mentors and sponsors. One former learner mentioned, “I think some of the administration, there are definitely females that are helping promote [the attending].” During an observation, Attending 1 indicated that she was part of a network of women and junior faculty forged to promote each other’s work since “some people are good at self-promotion and some are not.” This group shares accomplishments by distributing and publicizing their accolades.

This multisite, qualitative study informs the complex ways in which exemplary female teaching attendings must navigate being women in medicine. We identified myriad challenges female attendings face originating from patients, from healthcare workers, and within themselves. Our attendings relied upon the following key strategies to mitigate such challenges: (1) they actively position themselves as physician team leaders, (2) they consciously work to manage gender-based stereotypes and perceptions, and (3) they intentionally identify and embrace their unique qualities.

Prior scholarship surrounding gender-based challenges has focused primarily on strategies to improve healthcare systems for women. Much scrutiny has been placed on elevating institutional culture,^26-29 enacting clear policy surrounding sexual harassment,³⁰ ensuring women are actively recruited and retained,³¹ providing resources to assist in work-life balance,^26,32 and cultivating effective mentorship and social networks.^11,33,34

While our findings support the importance of improving healthcare systems, they are more congruent with recent scholarship on explicit personal tactics to mitigate gender-based challenges. Researchers have suggested physicians use algorithmic responses to patient-initiated sexual harassment,³⁵ advocate for those who experience harassment in real time,³⁶ and engage in dedicated practice responding to harassment.^37,38 Our results build on these studies by outlining strategies intended to navigate complex gender dynamics and role model approaches for learners. Interestingly, it was more common for attendings to discuss how they guide their learners and debrief after difficult situations than to discuss how they personally respond to gender-based harassment. While we are not certain why this occurred, three factors may have contributed. First, attendings mentioned that these conversations are often uncomfortable. Second, attendings appeared to accept a higher level of gender-based challenges than they would have tolerated for their learners. Lastly, although we did not gather demographic data from learners, several attendings voiced a strong desire to advocate for and equip female learners with strategies to address and navigate these challenges for themselves.

Gender stereotypes are ubiquitous and firmly rooted in long-standing belief patterns. Certain characteristics are considered masculine (eg, aggressiveness, confidence) and others feminine (eg, kindness, cooperation).¹⁰ Role congruity theory purports that stereotypes lead women to demonstrate behaviors that reflect socially accepted gender norms³⁹ and that social approval is at risk if they behave in ways discordant with these norms.^10,40 Our study provides perspectives from female physicians who walk the tightrope of forcefully asserting themselves more than their male counterparts while not being overly aggressive, since both approaches may have negative connotations.

This study has several limitations. First, it was conducted with a limited number of site visits, attendings, and learners. Likewise, attendings were internists with relatively advanced academic rank. This may reduce the study’s generalizability since attendings in other fields and at earlier career stages may utilize different strategies. However, we believe that if more senior-level female attendings experienced difficulties being recognized and legitimized in their roles, then one can assume that junior-level female faculty would experience these challenges even more so. Likewise, data saturation was not the goal of this exploratory study. Through intensive qualitative data collection, we sought to obtain an in-depth understanding of challenges and strategies. Second, many exemplary female attendings were overlooked by our selection methodology, particularly since women are often underrepresented in the factors we chose. The multisite design, modified snowball sampling, and purposeful randomized selection methodology were used to ensure quality and diversity. Third, attendings provided lists of their former learners, and thus, selection and recall biases may have been introduced since attendings may have more readily identified learners with whom they formed positive relationships. Finally, we cannot eliminate a potential Hawthorne effect on data collection. Researchers attempted to lessen this by standing apart from teams and remaining unobtrusive.

We identified strategies employed by exemplary female attendings to navigate gender-based challenges in their workplaces. We found that female attendings face unconscious bias, labels, power struggles, and harassment, simply because of their gender. They consciously and constantly navigate these challenges by positioning themselves to be seen and heard as team leaders, balancing aspects of their outward appearance and demeanor, embracing their differences and avoiding assimilation to masculine stereotypes of physician leaders, working to manage self-doubt, and coaching their female learners in these areas.

The authors are indebted to Suzanne Winter, MS, for assisting with coordination of study participants and site visits.

The demographic composition of physicians has shifted dramatically in the last five decades. The number of women matriculating into medical school rose from 6% in the 1960s¹ to 52% in 2019²; women accounted for 39% of full-time faculty in 2015.³ Despite this evolution of the physician gender array, many challenges remain.⁴ Women represented only 35% of all associate professors and 22% of full professors in 2015.³ Women experience gender-based discrimination, hostility, and unconscious bias as medical trainees^5-9 and as attending physicians^10-13 with significant deleterious effects including burnout and suicidal thoughts.¹⁴ While types of gender-based challenges are well described in the literature, strategies to navigate and respond to these challenges are less understood.

The approaches and techniques of exemplary teaching attending physicians (hereafter referred to as “attendings”) have previously been reported from groups of predominantly male attendings.^15-18 Because of gender-based challenges female physicians face that lead them to reduce their effort or leave the medical field,¹⁹ there is concern that prior scholarship in effective teaching may not adequately capture the approaches and techniques of female attendings. To our knowledge, no studies have specifically examined female attendings. Therefore, we sought to explore the lived experiences of six female attendings with particular emphasis on how they navigate and respond to gender-based challenges in clinical environments.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. We aimed to examine techniques, approaches, and attitudes of outstanding general medicine teaching attendings among groups previously not well represented (ie, women and self-identified underrepresented minorities [URMs] in medicine). URM was defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.”²⁰ A modified snowball sampling approach²¹ was employed to identify attendings as delineated below.

To maintain quality while guaranteeing diversity in geography and population, potential institutions in which to observe attendings were determined by first creating the following lists: The top 20 hospitals in the U.S. News & World Report’s 2017-2018 Best Hospitals Honor Roll,²² top-rated institutions by Doximity in each geographic region and among rural training sites,²³ and four historically Black colleges and universities (HBCUs) with medical schools. Institutions visited during a previous similar study¹⁶ were excluded. Next, the list was narrowed to 25 by randomly selecting five in each main geographic region and five rural institutions. These were combined with all four HBCUs to create a final list of 29 institutions.

Next, division of hospital medicine chiefs (and/or general medicine chiefs) and internal medicine residency directors at each of these 29 institutions were asked to nominate exemplary attendings, particularly those who identified as women and URMs. Twelve attendings who were themselves observed in a previous study¹⁶ were also asked for nominations. Finally, recommendations were sought from leaders of relevant American Medical Association member groups.²⁴

Using this sampling method, 43 physicians were identified. An internet search was conducted to identify individual characteristics including medical education, training, clinical and research interests, and educational awards. These characteristics were considered and discussed by the research team. Preference was given to those attendings nominated by more than one individual (n = 3), those who had received teaching awards, and those with interests involving women in medicine. Research team members narrowed the list to seven attendings who were contacted via email and invited to participate. One did not respond, while six agreed to participate. The six attendings identified current team members who would be rounding on the visit date. Attendings were asked to recommend 6-10 former learners; we contacted these former learners and invited them to participate. Former learners were included to understand lasting effects from their attendings.

Data Collection

Observations

All 1-day site visits were conducted by two research team members, a physician (NH) and a qualitative research specialist (MQ). In four visits, an additional author accompanied the research team. In order to ensure consistency and diversity in perspectives, all authors attended at least one visit. These occurred between April 16 and August 28, 2018. Each visit began with direct observation of attendings (n = 6) and current learners (n = 24) during inpatient general medicine teaching rounds. Each researcher unobtrusively recorded their observations via handwritten, open field notes, paying particular attention to group interactions, teaching approach, conversations within and peripheral to the team, and patient–team interactions. After each visit, researchers met to compare and combine field notes.

Interviews and Focus Groups

Researchers then conducted individual, semistructured interviews with attendings and focus groups with current (n = 21) and former (n = 17) learners. Focus groups with learners varied in size from two to five participants. Former learners were occasionally not available for on-site focus groups and were interviewed separately by telephone after the visit. The interview guide for attendings (Appendix 1) was adapted from the prior study¹⁶ but expanded with questions related to experiences, challenges, and approaches of female and URM physicians. A separate guide was used to facilitate focus groups with learners (Appendix 1). Three current learners were unable to participate in focus groups due to clinical duties. All interviews and focus groups were audio recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a content analysis approach.²⁵ Inductive coding was used to identify codes derived from the data. Two team members (MQ and MH) independently coded the first transcript to develop a codebook, then met to compare and discuss codes. Codes and definitions were entered into the codebook. These team members continued coding five additional transcripts, meeting to compare codes, discussing any discrepancies until agreement was reached, adding new codes identified, and ensuring consistent code application. They reviewed prior transcripts and recoded if necessary. Once no new codes were identified, one team member coded the remaining transcripts. The same codebook was used to code field note documents using the same iterative process. After all qualitative data were coded and verified, they were entered into NVivo 10. Code reports were generated and reviewed by three team members to identify themes and check for coding consistency.

Role of the Funding Source

This study received no external funding.

We examined six exemplary attendings through direct observation of rounds and individual interviews. We also discussed these attendings with 21 current learners and 17 former learners (Appendix 2). All attendings self-identified as female. The group was diverse in terms of race/ethnicity, with three identifying as Black or African American, two as Asian, and one as White or Caucasian. Levels of experience as an attending ranged from 8 to 20 years (mean, 15.3 years). At the time of observation, two were professors and four were associate professors. The group included all three attendings who had been nominated by more than one individual, and all six had won multiple teaching awards. The observation sites represented several areas of the United States (Table 1).

The coded interview data and field notes were categorized into three broad overlapping themes based on strategies our attendings used to respond to gender-based challenges. The following sections describe types of challenges faced by female attendings along with specific strategies they employed to actively position themselves as physician team leaders, manage gender-based stereotypes and perceptions, and identify and embrace their unique qualities. Illustrative quotations or observations that further elucidate meaning are provided.

Female Attendings Actively Position Themselves as Physician Team Leaders

Our attendings frequently stated that they were assumed to be other healthcare provider types, such as nurses or physical therapists, and that these assumptions originated from patients, faculty, and staff (Table 2). Attending 3 commented, “I think every woman in this role has been mistaken for a different caretaker role, so lots of requests for nursing help. I’m sure I have taken more patients off of bed pans and brought more cups of water than maybe some of my male counterparts.” Some attendings responded to this challenge with the strategy of routinely wearing a white coat during rounds and patient encounters. This external visual cue was seen as a necessary reminder of the female attending role.

We found that patients and healthcare providers often believe teams are led by men, leading to a feeling of invisibility for female attendings. One current learner remarked, “If it was a new patient, more than likely, if we had a female attending, the patient’s eyes would always divert to the male physician.” This was not limited to patients. Attending 6 remembered comments from her consultants including, “‘Who is your attending? Let me talk with them,’ kind of assuming that I’m not the person making the decisions.” Female attendings would respond to this challenge by clearly introducing team members, including themselves, with roles and responsibilities. At times, this would require reintroductions and redirection if individuals still misidentified female team members.

Female attendings’ decision-making and thought processes were frequently second-guessed. This would often lead to power struggles with consultants, nurses, and learners. Attending 5 commented, “Even in residency, I felt this sometimes adversarial relationship with...female nurses where they would treat [female attendings] differently...questioning our decisions.” Female attendings would respond to this challenge by asserting themselves and demonstrating confidence with colleagues and at the bedside. This was an active process for women, as one former learner described: “[Female] attendings have to be a little bit more ‘on’—whatever ‘on’ is—more forceful, more direct....There is more slack given to a male attending.”

Female Attendings Consciously Work to Manage Gender-Based Stereotypes and Perceptions

Our attendings navigated gender-based stereotypes and perceptions, ranging from subtle microaggressions to overt sexual harassment (Table 3). This required balance between extremes of being perceived as “too nice” and “too aggressive,” each of which was associated with negativity. Attending 1 remarked, “I know that other [female] faculty struggle with that a bit, with being...assertive. They are assertive, and it’s interpreted [negatively].” Attending 6 described insidiously sexist comments from patients: “‘You are too young to be a physician, you are too pretty to be a physician.’ ‘Oh, the woman doctor...rather than just ‘doctor.’” During one observation of rounds, a patient remarked to the attending, “You have cold hands. You know, I’m going to have to warm those up.” Our attendings responded to these challenges by proactively avoiding characteristics and behaviors considered to be stereotypically feminine in order to draw attention to their qualities as physicians rather than as women. During interviews, some attendings directed conversation away from themselves and instead placed emphasis on coaching female learners to navigate their own demeanors, behaviors, and responses to gender bias and harassment. This would include intentional planning of how to carry oneself, as well as feedback and debrief sessions after instances of harassment.

Our attendings grappled with how to physically portray themselves to avoid gender-based stereotypes. Attending 6 said, “Sometimes you might be taken less seriously if you pay more attention to your makeup or jewelry.” The same attending recalled “times where people would say inappropriate things based on what I was wearing—and I know that doesn’t happen with my male colleagues.” Our attendings responded to this challenge through purposeful choices of attire, personal appearance, and even external facial expressions that would avoid drawing unwanted or negative personal attention outside of the attending role.

Female Attendings Intentionally Identify and Embrace Their Unique Qualities

Our attendings identified societal gender norms and “traditional” masculine expectations in medicine (Table 4). Attending 4 drew attention to her institution’s healthcare leaders by remarking, “I think that women in medicine have similar challenges as women in other professional fields....Well, I guess it is different in that the pictures on the wall behind me are all White men.” Female attendings responded to this challenge by eschewing stereotypical qualities and intentionally finding and exhibiting their own unique strengths (eg, teaching approaches, areas of expertise, communication styles). By embracing their unique strengths, attendings gained confidence and felt more comfortable as physicians and educators. Advice from Attending 3 for other female physicians encapsulated this strategy: “But if [medicine] is what you love doing, then find a style that works for you, even if it’s different....Embrace being different.”

Several attendings identified patterns of thought in themselves that caused them to doubt their accomplishments and have a persistent fear of being exposed as a fraud, commonly known as impostor syndrome. Attending 2 summarized this with, “I know it’s irrational a little bit, but part of me [asks], ‘Am I getting all these opportunities because I’m female, because I’m a minority?’” Our attendings responded by recognizing impostor syndrome and addressing it through repeated positive self-reinforcing thoughts and language and by “letting go” of the doubt. Attending 4 recalled her feelings after being announced as a teaching award recipient for the fourth year in a row: “It was just like something changed in me....Maybe you are a good attending. Maybe you are doing something that is resonating with a unique class of medical students year after year.”

Our interviews also revealed strategies used by female attendings to support and advance their own careers, as well as those of other female faculty, to address the effects of impostor syndrome. Our participants noted the important role of female mentors and sponsors. One former learner mentioned, “I think some of the administration, there are definitely females that are helping promote [the attending].” During an observation, Attending 1 indicated that she was part of a network of women and junior faculty forged to promote each other’s work since “some people are good at self-promotion and some are not.” This group shares accomplishments by distributing and publicizing their accolades.

This multisite, qualitative study informs the complex ways in which exemplary female teaching attendings must navigate being women in medicine. We identified myriad challenges female attendings face originating from patients, from healthcare workers, and within themselves. Our attendings relied upon the following key strategies to mitigate such challenges: (1) they actively position themselves as physician team leaders, (2) they consciously work to manage gender-based stereotypes and perceptions, and (3) they intentionally identify and embrace their unique qualities.

Prior scholarship surrounding gender-based challenges has focused primarily on strategies to improve healthcare systems for women. Much scrutiny has been placed on elevating institutional culture,^26-29 enacting clear policy surrounding sexual harassment,³⁰ ensuring women are actively recruited and retained,³¹ providing resources to assist in work-life balance,^26,32 and cultivating effective mentorship and social networks.^11,33,34

While our findings support the importance of improving healthcare systems, they are more congruent with recent scholarship on explicit personal tactics to mitigate gender-based challenges. Researchers have suggested physicians use algorithmic responses to patient-initiated sexual harassment,³⁵ advocate for those who experience harassment in real time,³⁶ and engage in dedicated practice responding to harassment.^37,38 Our results build on these studies by outlining strategies intended to navigate complex gender dynamics and role model approaches for learners. Interestingly, it was more common for attendings to discuss how they guide their learners and debrief after difficult situations than to discuss how they personally respond to gender-based harassment. While we are not certain why this occurred, three factors may have contributed. First, attendings mentioned that these conversations are often uncomfortable. Second, attendings appeared to accept a higher level of gender-based challenges than they would have tolerated for their learners. Lastly, although we did not gather demographic data from learners, several attendings voiced a strong desire to advocate for and equip female learners with strategies to address and navigate these challenges for themselves.

Gender stereotypes are ubiquitous and firmly rooted in long-standing belief patterns. Certain characteristics are considered masculine (eg, aggressiveness, confidence) and others feminine (eg, kindness, cooperation).¹⁰ Role congruity theory purports that stereotypes lead women to demonstrate behaviors that reflect socially accepted gender norms³⁹ and that social approval is at risk if they behave in ways discordant with these norms.^10,40 Our study provides perspectives from female physicians who walk the tightrope of forcefully asserting themselves more than their male counterparts while not being overly aggressive, since both approaches may have negative connotations.

This study has several limitations. First, it was conducted with a limited number of site visits, attendings, and learners. Likewise, attendings were internists with relatively advanced academic rank. This may reduce the study’s generalizability since attendings in other fields and at earlier career stages may utilize different strategies. However, we believe that if more senior-level female attendings experienced difficulties being recognized and legitimized in their roles, then one can assume that junior-level female faculty would experience these challenges even more so. Likewise, data saturation was not the goal of this exploratory study. Through intensive qualitative data collection, we sought to obtain an in-depth understanding of challenges and strategies. Second, many exemplary female attendings were overlooked by our selection methodology, particularly since women are often underrepresented in the factors we chose. The multisite design, modified snowball sampling, and purposeful randomized selection methodology were used to ensure quality and diversity. Third, attendings provided lists of their former learners, and thus, selection and recall biases may have been introduced since attendings may have more readily identified learners with whom they formed positive relationships. Finally, we cannot eliminate a potential Hawthorne effect on data collection. Researchers attempted to lessen this by standing apart from teams and remaining unobtrusive.

We identified strategies employed by exemplary female attendings to navigate gender-based challenges in their workplaces. We found that female attendings face unconscious bias, labels, power struggles, and harassment, simply because of their gender. They consciously and constantly navigate these challenges by positioning themselves to be seen and heard as team leaders, balancing aspects of their outward appearance and demeanor, embracing their differences and avoiding assimilation to masculine stereotypes of physician leaders, working to manage self-doubt, and coaching their female learners in these areas.

The authors are indebted to Suzanne Winter, MS, for assisting with coordination of study participants and site visits.

Diagnostic error—defined as a failure to establish an accurate and timely explanation of the patient’s health problem—is an important source of patient harm.¹ Data suggest that all patients will experience at least 1 diagnostic error in their lifetime.^2-4 Not surprisingly, diagnostic errors are among the leading categories of paid malpractice claims in the United States.⁵

Despite diagnostic errors being morbid and sometimes deadly in the hospital,^6,7 little is known about how residents and learners approach diagnostic decision making. Errors in diagnosis are believed to stem from cognitive or system failures,⁸ with errors in cognition believed to occur due to rapid, reflexive thinking operating in the absence of a more analytical, deliberate process. System-based problems (eg, lack of expert availability, technology barriers, and access to data) have also been cited as contributors.⁹ However, whether and how these apply to trainees is not known.

Therefore, we conducted a focused ethnography of inpatient medicine teams (ie, attendings, residents, interns, and medical students) in 2 affiliated teaching hospitals, aiming to (a) observe the process of diagnosis by trainees and (b) identify methods to improve the diagnostic process and prevent errors.

We designed a multimethod, focused ethnographic study to examine diagnostic decision making in hospital settings.^10,11 In contrast to anthropologic ethnographies that study entire fields using open-ended questions, our study was designed to examine the process of diagnosis from the perspective of clinicians engaged in this activity.¹¹ This approach allowed us to capture diagnostic decisions and cognitive and system-based factors in a manner currently lacking in the literature.¹²

Setting and Participants

Between January 2016 and May 2016, we observed the members of four inpatient internal medicine teaching teams at 2 affiliated teaching hospitals. We purposefully selected teaching teams for observation because they are the primary model of care in academic settings and we have expertise in carrying out similar studies.^13,14 Teaching teams typically consisted of a medical attending (senior-level physician), 1 senior resident (a second- or third-year postgraduate trainee), two interns (a trainee in their first postgraduate year), and two to four  medical students. Teams were selected at random using existing schedules and followed Monday to Friday so as to permit observation of work on call and noncall days. Owing to manpower limitations, weekend and night shifts were not observed. However, overnight events were captured during morning rounds.

Most of the teams began rounds at 8:30 AM. Typically, rounds lasted for 90–120 min and concluded with a recap (ie, “running the list”) with a review of explicit plans for patients after they had been evaluated by the attending. This discussion often occurred in the team rooms, with the attending leading the discussion with the trainees.

Data Collection

A multidisciplinary team, including clinicians (eg, physicians, nurses), nonclinicians (eg, qualitative researchers, social scientists), and healthcare engineers, conducted the observations. We observed preround activities of interns and residents before arrival of the attending (7:00 AM - 8:30 AM), followed by morning rounds with the entire team, and afternoon work that included senior residents, interns, and students.

To capture multiple aspects of the diagnostic process, we collected data using field notes modeled on components of the National Academy of Science model for diagnosis (Appendix).^1,15 This model encompasses phases of the diagnostic process (eg, data gathering, integration, formulation of a working diagnosis, treatment delivery, and outcomes) and the work system (team members, organization, technology and tools, physical environment, tasks).

Focus Groups and Interviews

At the end of weekly observations, we conducted focus groups with the residents and one-on- one interviews with the attendings. Focus groups with the residents were conducted to encourage a group discussion about the diagnostic process. Separate interviews with the attendings were performed to ensure that power differentials did not influence discussions. During focus groups, we specifically asked about challenges and possible solutions to improve diagnosis. Experienced qualitative methodologists (J.F., M.H., M.Q.) used semistructured interview guides for discussions (Appendix).

Data Analysis

After aggregating and reading the data, three reviewers (V.C., S.K., S.S.) began inductive analysis by handwriting notes and initial reflective thoughts to create preliminary codes. Multiple team members then reread the original field notes and the focus group/interview data to refine the preliminary codes and develop additional codes. Next, relationships between codes were identified and used to develop key themes. Triangulation of data collected from observations and interview/focus group sessions was carried out to compare data that we surmised with data that were verbalized by the team. The developed themes were discussed as a group to ensure consistency of major findings.

Ethical and Regulatory Oversight

This study was reviewed and approved by the Institutional Review Boards at the University of Michigan Health System (HUM-00106657) and the VA Ann Arbor Healthcare System (1-2016-010040).

Four teaching teams (4 attendings, 4 senior residents, 9 interns, and 14 medical students) were observed over 33 distinct shifts and 168 hours. Observations included morning rounds (96 h), postround call days (52 h), and postround non-call days (20 h). Morning rounds lasted an average of 127 min (range: 48-232 min) and included an average of 9 patients (range: 4-16 patients).

Themes Regarding the Diagnostic Process

We identified the following 4 primary themes related to the diagnostic process in teaching hospitals: (1) diagnosis is a social phenomenon; (2) data necessary to make diagnoses are fragmented; (3) distractions undermine the diagnostic process; and (4) time pressures interfere with diagnostic decision making (Appendix Table 1).

(1) Diagnosis is a Social Phenomenon.

Team members viewed the process of diagnosis as a social exchange of facts, findings, and strategies within a defined structure. The opportunity to discuss impressions with others was valued as a means to share, test, and process assumptions.

“Rounds are the most important part of the process. That is where we make most decisions in a collective, collaborative way with the attending present. We bounce ideas off each other.” (Intern)

Typical of social processes, variations based on time of day and schedule were observed. For instance, during call days, learners gathered data and formed working diagnosis and treatment plans with minimal attending interaction. This separation of roles and responsibilities introduced a hierarchy within diagnosis as follows:

“The interns would not call me first; they would talk to the senior resident and then if the senior thought he should chat with me, then they would call. But for the most part, they gather information and come up with the plan.” (Attending).

The work system was suited to facilitate social interactions. For instance, designated rooms (with team members informally assigned to a computer) provided physical proximity of the resident to interns and medical students. In this space, numerous informal discussions between team members (eg, “What do you think about this test?” “I’m not sure what to do about this finding.” “Should I call a [consult] on this patient?”) were observed. Although proximity to each other was viewed as beneficial, dangers to the social nature of diagnosis in the form of anchoring (ie, a cognitive bias where emphasis is placed on the first piece of data)¹⁶ were also mentioned. Similarly, the paradox associated with social proof (ie, the pressure to assume conformity within a group) was also observed as disagreement between team members and attendings rarely occurred during observations.

“I mean, they’re the attending, right? It’s hard to argue with them when they want a test or something done. When I do push back, it’s rare that others will support me–so it’s usually me and the attending.” (Resident)

“I would push back if I think it’s really bad for the patient or could cause harm–but the truth is, it doesn’t happen much.” (Intern)

(2) Data Necessary to Make Diagnoses are Fragmented

Team members universally cited fragmentation in data delivery, retrieval, and processing as a barrier to diagnosis. Team members indicated that test results might not be looked at or acted upon in a timely manner, and participants pointed to the electronic medical record as a source of this challenge.

“Before I knew about [the app for Epic], I would literally sit on the computer to get all the information we would need on rounds. Its key to making decisions. We often say we will do something, only to find the test result doesn’t support it–and then we’re back to square 1.” (Intern)

Information used by teams came from myriad sources (eg, patients, family members, electronic records) and from various settings (eg, emergency department, patient rooms, discussions with consultants). Additionally, test results often appeared without warning. Thus, availability of information was poorly aligned with clinical duties.

“They (the lab) will call us when a blood culture is positive or something is off. That is very helpful but it often comes later in the day, when we’re done with rounds.” (Resident)

The work system was highlighted as a key contributor to data fragmentation. Peculiarities of our electronic medical record (EMR) and how data were collected, stored, or presented were described as “frustrating,” and “unsafe,” by team members. Correspondingly, we frequently observed interns asking for assistance for tasks such as ordering tests or finding information despite being “trained” to use the EMR.

“People have to learn how to filter, how to recognize the most important points and link data streams together in terms of causality. But we assume they know where to find that information. It’s actually a very hard thing to do, for both the house staff and me.” (Attending)

(3) Distractions Undermine the Diagnostic Process

Distractions often created cognitive difficulties. For example, ambient noise and interruptions from neighbors working on other teams were cited as barriers to diagnosis. In addition, we observed several team members using headphones to drown out ambient noise while working on the computer.

“I know I shouldn’t do it (wear headphones), but I have no other way of turning down the noise so I can concentrate.” (Intern)

Similarly, the unpredictable nature and the volume of pages often interrupted thinking about diagnosis.

“Sometimes the pager just goes off all the time and (after making sure its not an urgent issue), I will just ignore it for a bit, especially if I am in the middle of something. It would be great if I could finish my thought process knowing I would not be interrupted.” (Resident)

To mitigate this problem, 1 attending described how he would proactively seek out nurses caring for his patients to “head off” questions (eg, “I will renew the restraints and medications this morning,” and “Is there anything you need in terms of orders for this patient that I can take care of now?”) that might lead to pages. Another resident described his approach as follows:

“I make it a point to tell the nurses where I will be hanging out and where they can find me if they have any questions. I tell them to come talk to me rather than page me since that will be less distracting.” (Resident).

Most of the interns described documentation work such as writing admission and progress notes in negative terms (“an academic exercise,” “part of the billing activity”). However, in the context of interruptions, some described this as helpful.

“The most valuable part of the thinking process was writing the assessment and plan because that’s actually my schema for all problems. It literally is the only time where I can sit and collect my thoughts to formulate a diagnosis and plan.” (Intern)

(4) Time Pressures Interfere With Diagnostic Decision Making

All team members spoke about the challenge of finding time for diagnosis during the workday. Often, they had to skip learning sessions for this purpose.

“They tell us we should go to morning report or noon conference but when I’m running around trying to get things done. I hate having to choose between my education and doing what’s best for the patient–but that’s often what it comes down to.” (Intern)

When specifically asked whether setting aside dedicated time to specifically review and formulate diagnoses would be valuable, respondents were uniformly enthusiastic. Team members described attentional conflicts as being the worst when “cross covering” other teams on call days, as their patient load effectively doubled during this time. Of note, cross-covering occurred when teams were also on call—and thus took them away from important diagnostic activities such as data gathering or synthesis for patients they were admitting.

“If you were to ever design a system where errors were likely–this is how you would design it: take a team with little supervision, double their patient load, keep them busy with new challenging cases and then ask questions about patients they know little about.” (Resident)

Although diagnostic errors have been called “the next frontier for patient safety,”¹⁷ little is known about the process, barriers, and facilitators to diagnosis in teaching hospitals. In this focused ethnography conducted at 2 academic medical centers, we identified multiple cognitive and system-level challenges and potential strategies to improve diagnosis from trainees engaged in this activity. Key themes identified by those we observed included the social nature of diagnosis, fragmented information delivery, constant distractions and interruptions, and time pressures. In turn, these insights allow us to generate strategies that can be applied to improve the diagnostic process in teaching hospitals.

Our study underscores the importance of social interactions in diagnosis. In contrast, most of the interventions to prevent diagnostic errors target individual providers through practices such as metacognition and “thinking about thinking.”^18-20 These interventions are based on Daniel Kahnemann’s work on dual thought process. Type 1 thought processes are fast, subconscious, reflexive, largely intuitive, and more vulnerable to error. In contrast, Type 2 processes are slower, deliberate, analytic, and less prone to error.²¹ Although an individual’s Type 2 thought capacity is limited, a major goal of cognitive interventions is to encourage Type 2 over Type 1 thinking, an approach termed “de-biasing.”^22-24 Unfortunately, cognitive interventions testing such approaches have suffered mixed results–perhaps because of lack of focus on collective wisdom or group thinking, which may be key to diagnosis from our findings.^9,25 In this sense, morning rounds were a social gathering used to strategize and develop care plans, but with limited time to think about diagnosis.²⁶ Introduction of defined periods for individuals to engage in diagnostic activities such as de-biasing (ie, asking “what else could this be)²⁷ before or after rounds may provide an opportunity for reflection and improving diagnosis. In addition, embedding tools such as diagnosis expanders and checklists within these defined time slots^28,29 may prove to be useful in reflecting on diagnosis and preventing diagnostic errors.

An unexpected yet important finding from this study were the challenges posed by distractions and the physical environment. Potentially maladaptive workarounds to these interruptions included use of headphones; more productive strategies included updating nurses with plans to avert pages and creating a list of activities to ensure that key tasks were not forgotten.^30,31 Applying lessons from aviation, a focused effort to limit distractions during key portions of the day, might be worth considering for diagnostic safety.³² Similarly, improving the environment in which diagnosis occurs—including creating spaces that are quiet, orderly, and optimized for thinking—may be valuable.³³Our study has limitations. First, our findings are limited to direct observations; we are thus unable to comment on how unobserved aspects of care (eg, cognitive processes) might have influenced our findings. Our observations of clinical care might also have introduced a Hawthorne effect. However, because we were closely integrated with teams and conducted focus groups to corroborate our assessments, we believe that this was not the case. Second, we did not identify diagnostic errors or link processes we observed to errors. Third, our approach is limited to 2 teaching centers, thereby limiting the generalizability of findings. Relatedly, we were only able to conduct observations during weekdays; differences in weekend and night resources might affect our insights.

The cognitive and system-based barriers faced by clinicians in teaching hospitals suggest that new methods to improve diagnosis are needed. Future interventions such as defined “time-outs” for diagnosis, strategies focused on limiting distractions, and methods to improve communication between team members are novel and have parallels in other industries. As challenges to quantify diagnostic errors abound,³⁴ improving cognitive- and system-based factors via reflection through communication, concentration, and organization is necessary to improve medical decision making in academic medical centers.

Disclosures

None declared for all coauthors.

Funding

This project was supported by grant number P30HS024385 from the Agency for Healthcare Research and Quality. The funding source played no role in study design, data acquisition, analysis or decision to report these data. Dr. Chopra is supported by a career development award from the Agency of Healthcare Research and Quality (1-K08-HS022835-01). Dr. Krein is supported by a VA Health Services Research and Development Research Career Scientist Award (RCS 11-222). Dr. Singh is partially supported by Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Department of Veterans Affairs.

Diagnostic error—defined as a failure to establish an accurate and timely explanation of the patient’s health problem—is an important source of patient harm.¹ Data suggest that all patients will experience at least 1 diagnostic error in their lifetime.^2-4 Not surprisingly, diagnostic errors are among the leading categories of paid malpractice claims in the United States.⁵

Despite diagnostic errors being morbid and sometimes deadly in the hospital,^6,7 little is known about how residents and learners approach diagnostic decision making. Errors in diagnosis are believed to stem from cognitive or system failures,⁸ with errors in cognition believed to occur due to rapid, reflexive thinking operating in the absence of a more analytical, deliberate process. System-based problems (eg, lack of expert availability, technology barriers, and access to data) have also been cited as contributors.⁹ However, whether and how these apply to trainees is not known.

Therefore, we conducted a focused ethnography of inpatient medicine teams (ie, attendings, residents, interns, and medical students) in 2 affiliated teaching hospitals, aiming to (a) observe the process of diagnosis by trainees and (b) identify methods to improve the diagnostic process and prevent errors.

We designed a multimethod, focused ethnographic study to examine diagnostic decision making in hospital settings.^10,11 In contrast to anthropologic ethnographies that study entire fields using open-ended questions, our study was designed to examine the process of diagnosis from the perspective of clinicians engaged in this activity.¹¹ This approach allowed us to capture diagnostic decisions and cognitive and system-based factors in a manner currently lacking in the literature.¹²

Setting and Participants

Between January 2016 and May 2016, we observed the members of four inpatient internal medicine teaching teams at 2 affiliated teaching hospitals. We purposefully selected teaching teams for observation because they are the primary model of care in academic settings and we have expertise in carrying out similar studies.^13,14 Teaching teams typically consisted of a medical attending (senior-level physician), 1 senior resident (a second- or third-year postgraduate trainee), two interns (a trainee in their first postgraduate year), and two to four  medical students. Teams were selected at random using existing schedules and followed Monday to Friday so as to permit observation of work on call and noncall days. Owing to manpower limitations, weekend and night shifts were not observed. However, overnight events were captured during morning rounds.

Most of the teams began rounds at 8:30 AM. Typically, rounds lasted for 90–120 min and concluded with a recap (ie, “running the list”) with a review of explicit plans for patients after they had been evaluated by the attending. This discussion often occurred in the team rooms, with the attending leading the discussion with the trainees.

Data Collection

A multidisciplinary team, including clinicians (eg, physicians, nurses), nonclinicians (eg, qualitative researchers, social scientists), and healthcare engineers, conducted the observations. We observed preround activities of interns and residents before arrival of the attending (7:00 AM - 8:30 AM), followed by morning rounds with the entire team, and afternoon work that included senior residents, interns, and students.

To capture multiple aspects of the diagnostic process, we collected data using field notes modeled on components of the National Academy of Science model for diagnosis (Appendix).^1,15 This model encompasses phases of the diagnostic process (eg, data gathering, integration, formulation of a working diagnosis, treatment delivery, and outcomes) and the work system (team members, organization, technology and tools, physical environment, tasks).

Focus Groups and Interviews

At the end of weekly observations, we conducted focus groups with the residents and one-on- one interviews with the attendings. Focus groups with the residents were conducted to encourage a group discussion about the diagnostic process. Separate interviews with the attendings were performed to ensure that power differentials did not influence discussions. During focus groups, we specifically asked about challenges and possible solutions to improve diagnosis. Experienced qualitative methodologists (J.F., M.H., M.Q.) used semistructured interview guides for discussions (Appendix).

Data Analysis

After aggregating and reading the data, three reviewers (V.C., S.K., S.S.) began inductive analysis by handwriting notes and initial reflective thoughts to create preliminary codes. Multiple team members then reread the original field notes and the focus group/interview data to refine the preliminary codes and develop additional codes. Next, relationships between codes were identified and used to develop key themes. Triangulation of data collected from observations and interview/focus group sessions was carried out to compare data that we surmised with data that were verbalized by the team. The developed themes were discussed as a group to ensure consistency of major findings.

Ethical and Regulatory Oversight

This study was reviewed and approved by the Institutional Review Boards at the University of Michigan Health System (HUM-00106657) and the VA Ann Arbor Healthcare System (1-2016-010040).

Four teaching teams (4 attendings, 4 senior residents, 9 interns, and 14 medical students) were observed over 33 distinct shifts and 168 hours. Observations included morning rounds (96 h), postround call days (52 h), and postround non-call days (20 h). Morning rounds lasted an average of 127 min (range: 48-232 min) and included an average of 9 patients (range: 4-16 patients).

Themes Regarding the Diagnostic Process

We identified the following 4 primary themes related to the diagnostic process in teaching hospitals: (1) diagnosis is a social phenomenon; (2) data necessary to make diagnoses are fragmented; (3) distractions undermine the diagnostic process; and (4) time pressures interfere with diagnostic decision making (Appendix Table 1).

(1) Diagnosis is a Social Phenomenon.

Team members viewed the process of diagnosis as a social exchange of facts, findings, and strategies within a defined structure. The opportunity to discuss impressions with others was valued as a means to share, test, and process assumptions.

“Rounds are the most important part of the process. That is where we make most decisions in a collective, collaborative way with the attending present. We bounce ideas off each other.” (Intern)

Typical of social processes, variations based on time of day and schedule were observed. For instance, during call days, learners gathered data and formed working diagnosis and treatment plans with minimal attending interaction. This separation of roles and responsibilities introduced a hierarchy within diagnosis as follows:

“The interns would not call me first; they would talk to the senior resident and then if the senior thought he should chat with me, then they would call. But for the most part, they gather information and come up with the plan.” (Attending).

The work system was suited to facilitate social interactions. For instance, designated rooms (with team members informally assigned to a computer) provided physical proximity of the resident to interns and medical students. In this space, numerous informal discussions between team members (eg, “What do you think about this test?” “I’m not sure what to do about this finding.” “Should I call a [consult] on this patient?”) were observed. Although proximity to each other was viewed as beneficial, dangers to the social nature of diagnosis in the form of anchoring (ie, a cognitive bias where emphasis is placed on the first piece of data)¹⁶ were also mentioned. Similarly, the paradox associated with social proof (ie, the pressure to assume conformity within a group) was also observed as disagreement between team members and attendings rarely occurred during observations.

“I mean, they’re the attending, right? It’s hard to argue with them when they want a test or something done. When I do push back, it’s rare that others will support me–so it’s usually me and the attending.” (Resident)

“I would push back if I think it’s really bad for the patient or could cause harm–but the truth is, it doesn’t happen much.” (Intern)

(2) Data Necessary to Make Diagnoses are Fragmented

Team members universally cited fragmentation in data delivery, retrieval, and processing as a barrier to diagnosis. Team members indicated that test results might not be looked at or acted upon in a timely manner, and participants pointed to the electronic medical record as a source of this challenge.

“Before I knew about [the app for Epic], I would literally sit on the computer to get all the information we would need on rounds. Its key to making decisions. We often say we will do something, only to find the test result doesn’t support it–and then we’re back to square 1.” (Intern)

Information used by teams came from myriad sources (eg, patients, family members, electronic records) and from various settings (eg, emergency department, patient rooms, discussions with consultants). Additionally, test results often appeared without warning. Thus, availability of information was poorly aligned with clinical duties.

“They (the lab) will call us when a blood culture is positive or something is off. That is very helpful but it often comes later in the day, when we’re done with rounds.” (Resident)

The work system was highlighted as a key contributor to data fragmentation. Peculiarities of our electronic medical record (EMR) and how data were collected, stored, or presented were described as “frustrating,” and “unsafe,” by team members. Correspondingly, we frequently observed interns asking for assistance for tasks such as ordering tests or finding information despite being “trained” to use the EMR.

“People have to learn how to filter, how to recognize the most important points and link data streams together in terms of causality. But we assume they know where to find that information. It’s actually a very hard thing to do, for both the house staff and me.” (Attending)

(3) Distractions Undermine the Diagnostic Process

Distractions often created cognitive difficulties. For example, ambient noise and interruptions from neighbors working on other teams were cited as barriers to diagnosis. In addition, we observed several team members using headphones to drown out ambient noise while working on the computer.

“I know I shouldn’t do it (wear headphones), but I have no other way of turning down the noise so I can concentrate.” (Intern)

Similarly, the unpredictable nature and the volume of pages often interrupted thinking about diagnosis.

“Sometimes the pager just goes off all the time and (after making sure its not an urgent issue), I will just ignore it for a bit, especially if I am in the middle of something. It would be great if I could finish my thought process knowing I would not be interrupted.” (Resident)

To mitigate this problem, 1 attending described how he would proactively seek out nurses caring for his patients to “head off” questions (eg, “I will renew the restraints and medications this morning,” and “Is there anything you need in terms of orders for this patient that I can take care of now?”) that might lead to pages. Another resident described his approach as follows:

“I make it a point to tell the nurses where I will be hanging out and where they can find me if they have any questions. I tell them to come talk to me rather than page me since that will be less distracting.” (Resident).

Most of the interns described documentation work such as writing admission and progress notes in negative terms (“an academic exercise,” “part of the billing activity”). However, in the context of interruptions, some described this as helpful.

“The most valuable part of the thinking process was writing the assessment and plan because that’s actually my schema for all problems. It literally is the only time where I can sit and collect my thoughts to formulate a diagnosis and plan.” (Intern)

(4) Time Pressures Interfere With Diagnostic Decision Making

All team members spoke about the challenge of finding time for diagnosis during the workday. Often, they had to skip learning sessions for this purpose.

“They tell us we should go to morning report or noon conference but when I’m running around trying to get things done. I hate having to choose between my education and doing what’s best for the patient–but that’s often what it comes down to.” (Intern)

When specifically asked whether setting aside dedicated time to specifically review and formulate diagnoses would be valuable, respondents were uniformly enthusiastic. Team members described attentional conflicts as being the worst when “cross covering” other teams on call days, as their patient load effectively doubled during this time. Of note, cross-covering occurred when teams were also on call—and thus took them away from important diagnostic activities such as data gathering or synthesis for patients they were admitting.

“If you were to ever design a system where errors were likely–this is how you would design it: take a team with little supervision, double their patient load, keep them busy with new challenging cases and then ask questions about patients they know little about.” (Resident)

Although diagnostic errors have been called “the next frontier for patient safety,”¹⁷ little is known about the process, barriers, and facilitators to diagnosis in teaching hospitals. In this focused ethnography conducted at 2 academic medical centers, we identified multiple cognitive and system-level challenges and potential strategies to improve diagnosis from trainees engaged in this activity. Key themes identified by those we observed included the social nature of diagnosis, fragmented information delivery, constant distractions and interruptions, and time pressures. In turn, these insights allow us to generate strategies that can be applied to improve the diagnostic process in teaching hospitals.

Our study underscores the importance of social interactions in diagnosis. In contrast, most of the interventions to prevent diagnostic errors target individual providers through practices such as metacognition and “thinking about thinking.”^18-20 These interventions are based on Daniel Kahnemann’s work on dual thought process. Type 1 thought processes are fast, subconscious, reflexive, largely intuitive, and more vulnerable to error. In contrast, Type 2 processes are slower, deliberate, analytic, and less prone to error.²¹ Although an individual’s Type 2 thought capacity is limited, a major goal of cognitive interventions is to encourage Type 2 over Type 1 thinking, an approach termed “de-biasing.”^22-24 Unfortunately, cognitive interventions testing such approaches have suffered mixed results–perhaps because of lack of focus on collective wisdom or group thinking, which may be key to diagnosis from our findings.^9,25 In this sense, morning rounds were a social gathering used to strategize and develop care plans, but with limited time to think about diagnosis.²⁶ Introduction of defined periods for individuals to engage in diagnostic activities such as de-biasing (ie, asking “what else could this be)²⁷ before or after rounds may provide an opportunity for reflection and improving diagnosis. In addition, embedding tools such as diagnosis expanders and checklists within these defined time slots^28,29 may prove to be useful in reflecting on diagnosis and preventing diagnostic errors.

An unexpected yet important finding from this study were the challenges posed by distractions and the physical environment. Potentially maladaptive workarounds to these interruptions included use of headphones; more productive strategies included updating nurses with plans to avert pages and creating a list of activities to ensure that key tasks were not forgotten.^30,31 Applying lessons from aviation, a focused effort to limit distractions during key portions of the day, might be worth considering for diagnostic safety.³² Similarly, improving the environment in which diagnosis occurs—including creating spaces that are quiet, orderly, and optimized for thinking—may be valuable.³³Our study has limitations. First, our findings are limited to direct observations; we are thus unable to comment on how unobserved aspects of care (eg, cognitive processes) might have influenced our findings. Our observations of clinical care might also have introduced a Hawthorne effect. However, because we were closely integrated with teams and conducted focus groups to corroborate our assessments, we believe that this was not the case. Second, we did not identify diagnostic errors or link processes we observed to errors. Third, our approach is limited to 2 teaching centers, thereby limiting the generalizability of findings. Relatedly, we were only able to conduct observations during weekdays; differences in weekend and night resources might affect our insights.

The cognitive and system-based barriers faced by clinicians in teaching hospitals suggest that new methods to improve diagnosis are needed. Future interventions such as defined “time-outs” for diagnosis, strategies focused on limiting distractions, and methods to improve communication between team members are novel and have parallels in other industries. As challenges to quantify diagnostic errors abound,³⁴ improving cognitive- and system-based factors via reflection through communication, concentration, and organization is necessary to improve medical decision making in academic medical centers.

Disclosures

None declared for all coauthors.

Funding

This project was supported by grant number P30HS024385 from the Agency for Healthcare Research and Quality. The funding source played no role in study design, data acquisition, analysis or decision to report these data. Dr. Chopra is supported by a career development award from the Agency of Healthcare Research and Quality (1-K08-HS022835-01). Dr. Krein is supported by a VA Health Services Research and Development Research Career Scientist Award (RCS 11-222). Dr. Singh is partially supported by Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Department of Veterans Affairs.

Diagnostic error—defined as a failure to establish an accurate and timely explanation of the patient’s health problem—is an important source of patient harm.¹ Data suggest that all patients will experience at least 1 diagnostic error in their lifetime.^2-4 Not surprisingly, diagnostic errors are among the leading categories of paid malpractice claims in the United States.⁵

Despite diagnostic errors being morbid and sometimes deadly in the hospital,^6,7 little is known about how residents and learners approach diagnostic decision making. Errors in diagnosis are believed to stem from cognitive or system failures,⁸ with errors in cognition believed to occur due to rapid, reflexive thinking operating in the absence of a more analytical, deliberate process. System-based problems (eg, lack of expert availability, technology barriers, and access to data) have also been cited as contributors.⁹ However, whether and how these apply to trainees is not known.

Therefore, we conducted a focused ethnography of inpatient medicine teams (ie, attendings, residents, interns, and medical students) in 2 affiliated teaching hospitals, aiming to (a) observe the process of diagnosis by trainees and (b) identify methods to improve the diagnostic process and prevent errors.

We designed a multimethod, focused ethnographic study to examine diagnostic decision making in hospital settings.^10,11 In contrast to anthropologic ethnographies that study entire fields using open-ended questions, our study was designed to examine the process of diagnosis from the perspective of clinicians engaged in this activity.¹¹ This approach allowed us to capture diagnostic decisions and cognitive and system-based factors in a manner currently lacking in the literature.¹²

Setting and Participants

Between January 2016 and May 2016, we observed the members of four inpatient internal medicine teaching teams at 2 affiliated teaching hospitals. We purposefully selected teaching teams for observation because they are the primary model of care in academic settings and we have expertise in carrying out similar studies.^13,14 Teaching teams typically consisted of a medical attending (senior-level physician), 1 senior resident (a second- or third-year postgraduate trainee), two interns (a trainee in their first postgraduate year), and two to four  medical students. Teams were selected at random using existing schedules and followed Monday to Friday so as to permit observation of work on call and noncall days. Owing to manpower limitations, weekend and night shifts were not observed. However, overnight events were captured during morning rounds.

Most of the teams began rounds at 8:30 AM. Typically, rounds lasted for 90–120 min and concluded with a recap (ie, “running the list”) with a review of explicit plans for patients after they had been evaluated by the attending. This discussion often occurred in the team rooms, with the attending leading the discussion with the trainees.

Data Collection

A multidisciplinary team, including clinicians (eg, physicians, nurses), nonclinicians (eg, qualitative researchers, social scientists), and healthcare engineers, conducted the observations. We observed preround activities of interns and residents before arrival of the attending (7:00 AM - 8:30 AM), followed by morning rounds with the entire team, and afternoon work that included senior residents, interns, and students.

To capture multiple aspects of the diagnostic process, we collected data using field notes modeled on components of the National Academy of Science model for diagnosis (Appendix).^1,15 This model encompasses phases of the diagnostic process (eg, data gathering, integration, formulation of a working diagnosis, treatment delivery, and outcomes) and the work system (team members, organization, technology and tools, physical environment, tasks).

Focus Groups and Interviews

At the end of weekly observations, we conducted focus groups with the residents and one-on- one interviews with the attendings. Focus groups with the residents were conducted to encourage a group discussion about the diagnostic process. Separate interviews with the attendings were performed to ensure that power differentials did not influence discussions. During focus groups, we specifically asked about challenges and possible solutions to improve diagnosis. Experienced qualitative methodologists (J.F., M.H., M.Q.) used semistructured interview guides for discussions (Appendix).

Data Analysis

After aggregating and reading the data, three reviewers (V.C., S.K., S.S.) began inductive analysis by handwriting notes and initial reflective thoughts to create preliminary codes. Multiple team members then reread the original field notes and the focus group/interview data to refine the preliminary codes and develop additional codes. Next, relationships between codes were identified and used to develop key themes. Triangulation of data collected from observations and interview/focus group sessions was carried out to compare data that we surmised with data that were verbalized by the team. The developed themes were discussed as a group to ensure consistency of major findings.

Ethical and Regulatory Oversight

This study was reviewed and approved by the Institutional Review Boards at the University of Michigan Health System (HUM-00106657) and the VA Ann Arbor Healthcare System (1-2016-010040).

Four teaching teams (4 attendings, 4 senior residents, 9 interns, and 14 medical students) were observed over 33 distinct shifts and 168 hours. Observations included morning rounds (96 h), postround call days (52 h), and postround non-call days (20 h). Morning rounds lasted an average of 127 min (range: 48-232 min) and included an average of 9 patients (range: 4-16 patients).

Themes Regarding the Diagnostic Process

We identified the following 4 primary themes related to the diagnostic process in teaching hospitals: (1) diagnosis is a social phenomenon; (2) data necessary to make diagnoses are fragmented; (3) distractions undermine the diagnostic process; and (4) time pressures interfere with diagnostic decision making (Appendix Table 1).

(1) Diagnosis is a Social Phenomenon.

Team members viewed the process of diagnosis as a social exchange of facts, findings, and strategies within a defined structure. The opportunity to discuss impressions with others was valued as a means to share, test, and process assumptions.

“Rounds are the most important part of the process. That is where we make most decisions in a collective, collaborative way with the attending present. We bounce ideas off each other.” (Intern)

Typical of social processes, variations based on time of day and schedule were observed. For instance, during call days, learners gathered data and formed working diagnosis and treatment plans with minimal attending interaction. This separation of roles and responsibilities introduced a hierarchy within diagnosis as follows:

“The interns would not call me first; they would talk to the senior resident and then if the senior thought he should chat with me, then they would call. But for the most part, they gather information and come up with the plan.” (Attending).

The work system was suited to facilitate social interactions. For instance, designated rooms (with team members informally assigned to a computer) provided physical proximity of the resident to interns and medical students. In this space, numerous informal discussions between team members (eg, “What do you think about this test?” “I’m not sure what to do about this finding.” “Should I call a [consult] on this patient?”) were observed. Although proximity to each other was viewed as beneficial, dangers to the social nature of diagnosis in the form of anchoring (ie, a cognitive bias where emphasis is placed on the first piece of data)¹⁶ were also mentioned. Similarly, the paradox associated with social proof (ie, the pressure to assume conformity within a group) was also observed as disagreement between team members and attendings rarely occurred during observations.

“I mean, they’re the attending, right? It’s hard to argue with them when they want a test or something done. When I do push back, it’s rare that others will support me–so it’s usually me and the attending.” (Resident)

“I would push back if I think it’s really bad for the patient or could cause harm–but the truth is, it doesn’t happen much.” (Intern)

(2) Data Necessary to Make Diagnoses are Fragmented

Team members universally cited fragmentation in data delivery, retrieval, and processing as a barrier to diagnosis. Team members indicated that test results might not be looked at or acted upon in a timely manner, and participants pointed to the electronic medical record as a source of this challenge.

“Before I knew about [the app for Epic], I would literally sit on the computer to get all the information we would need on rounds. Its key to making decisions. We often say we will do something, only to find the test result doesn’t support it–and then we’re back to square 1.” (Intern)

Information used by teams came from myriad sources (eg, patients, family members, electronic records) and from various settings (eg, emergency department, patient rooms, discussions with consultants). Additionally, test results often appeared without warning. Thus, availability of information was poorly aligned with clinical duties.

“They (the lab) will call us when a blood culture is positive or something is off. That is very helpful but it often comes later in the day, when we’re done with rounds.” (Resident)

The work system was highlighted as a key contributor to data fragmentation. Peculiarities of our electronic medical record (EMR) and how data were collected, stored, or presented were described as “frustrating,” and “unsafe,” by team members. Correspondingly, we frequently observed interns asking for assistance for tasks such as ordering tests or finding information despite being “trained” to use the EMR.

“People have to learn how to filter, how to recognize the most important points and link data streams together in terms of causality. But we assume they know where to find that information. It’s actually a very hard thing to do, for both the house staff and me.” (Attending)

(3) Distractions Undermine the Diagnostic Process

Distractions often created cognitive difficulties. For example, ambient noise and interruptions from neighbors working on other teams were cited as barriers to diagnosis. In addition, we observed several team members using headphones to drown out ambient noise while working on the computer.

“I know I shouldn’t do it (wear headphones), but I have no other way of turning down the noise so I can concentrate.” (Intern)

Similarly, the unpredictable nature and the volume of pages often interrupted thinking about diagnosis.

“Sometimes the pager just goes off all the time and (after making sure its not an urgent issue), I will just ignore it for a bit, especially if I am in the middle of something. It would be great if I could finish my thought process knowing I would not be interrupted.” (Resident)

To mitigate this problem, 1 attending described how he would proactively seek out nurses caring for his patients to “head off” questions (eg, “I will renew the restraints and medications this morning,” and “Is there anything you need in terms of orders for this patient that I can take care of now?”) that might lead to pages. Another resident described his approach as follows:

“I make it a point to tell the nurses where I will be hanging out and where they can find me if they have any questions. I tell them to come talk to me rather than page me since that will be less distracting.” (Resident).

Most of the interns described documentation work such as writing admission and progress notes in negative terms (“an academic exercise,” “part of the billing activity”). However, in the context of interruptions, some described this as helpful.

“The most valuable part of the thinking process was writing the assessment and plan because that’s actually my schema for all problems. It literally is the only time where I can sit and collect my thoughts to formulate a diagnosis and plan.” (Intern)

(4) Time Pressures Interfere With Diagnostic Decision Making

All team members spoke about the challenge of finding time for diagnosis during the workday. Often, they had to skip learning sessions for this purpose.

“They tell us we should go to morning report or noon conference but when I’m running around trying to get things done. I hate having to choose between my education and doing what’s best for the patient–but that’s often what it comes down to.” (Intern)

When specifically asked whether setting aside dedicated time to specifically review and formulate diagnoses would be valuable, respondents were uniformly enthusiastic. Team members described attentional conflicts as being the worst when “cross covering” other teams on call days, as their patient load effectively doubled during this time. Of note, cross-covering occurred when teams were also on call—and thus took them away from important diagnostic activities such as data gathering or synthesis for patients they were admitting.

“If you were to ever design a system where errors were likely–this is how you would design it: take a team with little supervision, double their patient load, keep them busy with new challenging cases and then ask questions about patients they know little about.” (Resident)

Although diagnostic errors have been called “the next frontier for patient safety,”¹⁷ little is known about the process, barriers, and facilitators to diagnosis in teaching hospitals. In this focused ethnography conducted at 2 academic medical centers, we identified multiple cognitive and system-level challenges and potential strategies to improve diagnosis from trainees engaged in this activity. Key themes identified by those we observed included the social nature of diagnosis, fragmented information delivery, constant distractions and interruptions, and time pressures. In turn, these insights allow us to generate strategies that can be applied to improve the diagnostic process in teaching hospitals.

Our study underscores the importance of social interactions in diagnosis. In contrast, most of the interventions to prevent diagnostic errors target individual providers through practices such as metacognition and “thinking about thinking.”^18-20 These interventions are based on Daniel Kahnemann’s work on dual thought process. Type 1 thought processes are fast, subconscious, reflexive, largely intuitive, and more vulnerable to error. In contrast, Type 2 processes are slower, deliberate, analytic, and less prone to error.²¹ Although an individual’s Type 2 thought capacity is limited, a major goal of cognitive interventions is to encourage Type 2 over Type 1 thinking, an approach termed “de-biasing.”^22-24 Unfortunately, cognitive interventions testing such approaches have suffered mixed results–perhaps because of lack of focus on collective wisdom or group thinking, which may be key to diagnosis from our findings.^9,25 In this sense, morning rounds were a social gathering used to strategize and develop care plans, but with limited time to think about diagnosis.²⁶ Introduction of defined periods for individuals to engage in diagnostic activities such as de-biasing (ie, asking “what else could this be)²⁷ before or after rounds may provide an opportunity for reflection and improving diagnosis. In addition, embedding tools such as diagnosis expanders and checklists within these defined time slots^28,29 may prove to be useful in reflecting on diagnosis and preventing diagnostic errors.

An unexpected yet important finding from this study were the challenges posed by distractions and the physical environment. Potentially maladaptive workarounds to these interruptions included use of headphones; more productive strategies included updating nurses with plans to avert pages and creating a list of activities to ensure that key tasks were not forgotten.^30,31 Applying lessons from aviation, a focused effort to limit distractions during key portions of the day, might be worth considering for diagnostic safety.³² Similarly, improving the environment in which diagnosis occurs—including creating spaces that are quiet, orderly, and optimized for thinking—may be valuable.³³Our study has limitations. First, our findings are limited to direct observations; we are thus unable to comment on how unobserved aspects of care (eg, cognitive processes) might have influenced our findings. Our observations of clinical care might also have introduced a Hawthorne effect. However, because we were closely integrated with teams and conducted focus groups to corroborate our assessments, we believe that this was not the case. Second, we did not identify diagnostic errors or link processes we observed to errors. Third, our approach is limited to 2 teaching centers, thereby limiting the generalizability of findings. Relatedly, we were only able to conduct observations during weekdays; differences in weekend and night resources might affect our insights.

The cognitive and system-based barriers faced by clinicians in teaching hospitals suggest that new methods to improve diagnosis are needed. Future interventions such as defined “time-outs” for diagnosis, strategies focused on limiting distractions, and methods to improve communication between team members are novel and have parallels in other industries. As challenges to quantify diagnostic errors abound,³⁴ improving cognitive- and system-based factors via reflection through communication, concentration, and organization is necessary to improve medical decision making in academic medical centers.

Disclosures

None declared for all coauthors.

Funding

This project was supported by grant number P30HS024385 from the Agency for Healthcare Research and Quality. The funding source played no role in study design, data acquisition, analysis or decision to report these data. Dr. Chopra is supported by a career development award from the Agency of Healthcare Research and Quality (1-K08-HS022835-01). Dr. Krein is supported by a VA Health Services Research and Development Research Career Scientist Award (RCS 11-222). Dr. Singh is partially supported by Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Department of Veterans Affairs.

Approximately a century ago, Francis Peabody taught that “the secret of the care of the patient is in caring for the patient.”¹ His advice remains true today. Despite the advent of novel diagnostic tests, technologically sophisticated interventional procedures, and life-saving medications, perhaps the most important skill a bedside clinician can use is the ability to connect with patients.

The literature on patient-physician interaction is vast^2-11 and generally indicates that exemplary bedside clinicians are able to interact well with patients by being competent, trustworthy, personable, empathetic, and effective communicators. “Etiquette-based medicine,” first proposed by Kahn,¹² emphasizes the importance of certain behaviors from physicians, such as introducing yourself and explaining your role, shaking hands, sitting down when speaking to patients, and asking open-ended questions.

Yet, improving patient-physician interactions remains necessary. A recent systematic review reported that almost half of the reviewed studies on the patient-physician relationship published between 2000 and 2014 conveyed the idea that the patient-physician relationship is deteriorating.¹³

As part of a broader study to understand the behaviors and approaches of exemplary inpatient attending physicians,^14-16 we examined how 12 carefully selected physicians interacted with their patients during inpatient teaching rounds.

Overview

We conducted a multisite study using an exploratory, qualitative approach to inquiry, which has been described previously.^14-16 Our primary purpose was to study the attributes and behaviors of outstanding general medicine attendings in the setting of inpatient rounds. The focus of this article is on the attendings’ interactions with patients.

We used a modified snowball sampling approach¹⁷ to identify 12 exemplary physicians. First, we contacted individuals throughout the United States who were known to the principal investigator (S.S.) and asked for suggestions of excellent clinician educators (also referred to as attendings) for potential inclusion in the study. In addition to these personal contacts, other individuals unknown to the investigative team were contacted and asked to provide suggestions for attendings to include in the study. Specifically, the US News & World Report 2015 Top Medical Schools: Research Rankings,¹⁸ which are widely used to represent the best U.S. hospitals, were reviewed in an effort to identify attendings from a broad range of medical schools. Using this list, we identified other medical schools that were in the top 25 and were not already represented. We contacted the division chiefs of general internal (or hospital) medicine, chairs and chiefs of departments of internal medicine, and internal medicine residency program directors from these medical schools and asked for recommendations of attendings from both within and outside their institutions whom they considered to be great inpatient teachers.

This sampling method resulted in 59 potential participants. An internet search was conducted on each potential participant to obtain further information about the individuals and their institutions. Both personal characteristics (medical education, training, and educational awards) and organizational characteristics (geographic location, hospital size and affiliation, and patient population) were considered so that a variety of organizations and backgrounds were represented. Through this process, the list was narrowed to 16 attendings who were contacted to participate in the study, of which 12 agreed. The number of attendings examined was appropriate because saturation of metathemes can occur in as little as 6 interviews, and data saturation occurs at 12 interviews.¹⁹ The participants were asked to provide a list of their current learners (ie, residents and medical students) and 6 to 10 former learners to contact for interviews and focus groups.

Data Collection

Observations

Two researchers conducted the one-day site visits. One was a physician (S.S.) and the other a medical anthropologist (M.H.), and both have extensive experience in qualitative methods. The only exception was the site visit at the principal investigator’s own institution, which was conducted by the medical anthropologist and a nonpracticing physician who was unknown to the participants. The team structure varied slightly among different institutions but in general was composed of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Each site visit began with observing the attendings (n = 12) and current learners (n = 57) on morning rounds, which included their interactions with patients. These observations lasted approximately 2 to 3 hours. The observers took handwritten field notes, paying particular attention to group interactions, teaching approaches, and patient interactions. The observers stood outside the medical team circle and remained silent during rounds so as to be unobtrusive to the teams’ discussions. The observers discussed and compared their notes after each site visit.

Interviews and Focus Groups

The research team also conducted individual, semistructured interviews with the attendings (n = 12), focus groups with their current teams (n = 46), and interviews or focus groups with their former learners (n = 26). Current learners were asked open-ended questions about their roles on the teams, their opinions of the attendings, and the care the attendings provide to their patients. Because they were observed during rounds, the researchers asked for clarification about specific interactions observed during the teaching rounds. Depending on availability and location, former learners either participated in in-person focus groups or interviews on the day of the site visit, or in a later telephone interview. All interviews and focus groups were audio recorded and transcribed.

This study was deemed to be exempt from regulation by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could refuse to answer any question.

Data Analysis

Data were analyzed using a thematic analysis approach,²⁰ which involves reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. The patterns are then grouped into themes to help further explain the findings.²¹ The research team members (S.S. and M.H.) met after the first site visit and developed initial ideas about meanings and possible patterns. One team member (M.H.) read all the transcripts from the site visit and, based on the data, developed a codebook to be used for this study. This process was repeated after every site visit, and the coding definitions were refined as necessary. All transcripts were reviewed to apply any new codes when they developed. NVivo^® 10 software (QSR International, Melbourne, Australia) was used to assist with the qualitative data analysis.

To ensure consistency and identify relationships between codes, code reports listing all the data linked to a specific code were generated after all the field notes and transcripts were coded. Once verified, codes were grouped based on similarities and relationships into prominent themes related to physician-patient interactions by 2 team members (S.S. and M.H.), though all members reviewed them and concurred.

Care for the Patient’s Well-Being

The attendings we observed appeared to openly care for their patients’ well-being and were focused on the patients’ wants and needs. We noted that attendings were generally very attentive to the patients’ comfort. For example, we observed one attending sending the senior resident to find the patient’s nurse in order to obtain additional pain medications. The attending said to the patient several times, “I’m sorry you’re in so much pain.” When the team was leaving, she asked the intern to stay with the patient until the medications had been administered.

Consideration of the “Big Picture”

Our exemplary attendings kept the “big picture” (that is, the patient’s overall medical and social needs) in clear focus. They behaved in a way to ensure that the patients understood the key points of their care and explained so the patients and families could understand. A current learner said, “[The attending] really makes sure that the patient understands what’s going on. And she always asks them, ‘What do you understand, what do you know, how can we fill in any blanks?’ And that makes the patient really involved in their own care, which I think is important.” This reflection was supported by direct observations. Attendings posed the following questions at the conclusion of patient interactions: “Tell me what you know.” “Tell me what our plan is.” “What did the lung doctors tell you yesterday?” These questions, which have been termed “teach-back” and are crucial for health literacy, were not meant to quiz the patient but rather to ensure the patient and family understood the plan.

We noticed that the attendings effectively explained clinical details and the plan of care to the patient while avoiding medical jargon. The following is an example of one interaction with a patient: “You threw up and created a tear in the food tube. Air got from that into the middle of the chest, not into the lungs. Air isn’t normally there. If it is just air, the body will reabsorb [it]... But we worry about bacteria getting in with the air. We need to figure out if it is an infection. We’re still trying to figure it out. Hang in there with us.” One learner commented, “… since we do bedside presentations, he has a great way of translating our gibberish, basically, to real language the patient understands.”

Finally, the attendings anticipated what patients would need in the outpatient setting. We observed that attendings stressed what the next steps would be during transitions of care. As one learner put it, “But he also thinks ahead; what do they need as an outpatient?” Another current learner commented on how another attending always asked about the social situations of his patients stating, “And then there is the social part of it. So, he is very much interested [in] where do they live? What is their support system? So, I think it has been a very holistic approach to patient care.”

Respect for the Patient

The attendings we observed were steadfastly respectful toward patients. As one attending told us, “The patient’s room is sacred space, and it’s a privilege for us to be there. And if we don’t earn that privilege, then we don’t get to go there.” We observed that the attendings generally referred to the patient as Mr. or Ms. (last name) rather than the patient’s first name unless the patient insisted. We also noticed that many of the attendings would introduce the team members to the patients or ask each member to introduce himself or herself. They also tended to leave the room and patient the way they were found, for example, by pushing the patient’s bedside table so that it was back within his or her reach or placing socks back onto the patient’s feet.

We noted that many of our attendings used appropriate humor with patients and families. As one learner explained, “I think Dr. [attending] makes most of our patients laugh during rounds. I don’t know if you noticed, but he really puts a smile on their face[s] whenever he walks in. … Maybe it would catch them off guard the first day, but after that, they are so happy to see him.”

Finally, we noticed that several of our attendings made sure to meet the patient at eye level during discussions by either kneeling or sitting on a chair. One of the attendings put it this way: “That’s a horrible power dynamic when you’re an inpatient and you’re sick and someone’s standing over you telling you things, and I like to be able to make eye contact with people, and often times that requires me to kneel down or to sit on a stool or to sit on the bed. … I feel like you’re able to connect with the people in a much better way…” Learners viewed this behavior favorably. As one told us, “[The attending] gets down to their level and makes sure that all of their questions are answered. So that is one thing that other attendings don’t necessarily do.”

In our national, qualitative study of 12 exemplary attending physicians, we found that these clinicians generally exhibited the following behaviors with patients. First, they were personable and caring and made significant attempts to connect with their patients. This occasionally took the form of using touch to comfort patients. Second, they tended to seek the “big picture” and tried to understand what patients would need upon hospital discharge. They communicated plans clearly to patients and families and inquired if those plans were understood. Finally, they showed respect toward their patients without fail. Such respect took many forms but included leaving the patient and room exactly as they were found and speaking with patients at eye level.

Our findings are largely consistent with other key studies in this field. Not surprisingly, the attendings we observed adhered to the major suggestions that Branch and colleagues² put forth more than 15 years ago to improve the teaching of the humanistic dimension of the patient-physician relationship. Examples include greeting the patient, introducing team members and explaining each person’s role, asking open-ended questions, providing patient education, placing oneself at the same level as the patient, using appropriate touch, and being respectful. Weissmann et al.²² also found similar themes in their study of teaching physicians at 4 universities from 2003 to 2004. In that study, role-modeling was the primary method used by physician educators to teach the humanistic aspects of medical care, including nonverbal communication (eg, touch and eye contact), demonstration of respect, and building a personal connection with the patients.²²In a focus group-based study performed at a teaching hospital in Boston, Ramani and Orlander²³ concluded that both participating teachers and learners considered the patient’s bedside as a valuable venue to learn humanistic skills. Unfortunately, they also noted that there has been a decline in bedside teaching related to various factors, including documentation requirements and electronic medical records.²³ Our attendings all demonstrated the value of teaching at a patient’s bedside. Not only could physical examination skills be demonstrated but role-modeling of interpersonal skills could be observed by learners.

Block and colleagues²⁴ observed 29 interns in 732 patient encounters in 2 Baltimore training programs using Kahn’s “etiquette-based medicine” behaviors as a guide.¹² They found that interns introduced themselves 40% of the time, explained their role 37% of the time, touched patients on 65% of visits (including as part of the physical examination), asked open-ended questions 75% of the time, and sat down with patients during only 9% of visits.²⁴ Tackett et al.⁷ observed 24 hospitalists who collectively cared for 226 unique patients in 3 Baltimore-area hospitals. They found that each of the following behaviors was performed less than 30% of the time: explains role in care, shakes hand, and sits down.⁷ However, our attendings appeared to adhere to these behaviors to a much higher extent, though we did not quantify the interactions. This lends support to the notion that effective patient-physician interactions are the foundation of great teaching.

The attendings we observed (most of whom are inpatient based) tended to the contextual issues of the patients, such as their home environments and social support. Our exemplary physicians did what they could to ensure that patients received the appropriate follow-up care upon discharge.

Our study has important limitations. First, it was conducted in a limited number of US hospitals. The institutions represented were generally large, research-intensive, academic medical centers. Therefore, our findings may not apply to settings that are different from the hospitals studied. Second, our study included only 12 attendings and their learners, which may also limit the study’s generalizability. Third, we focused exclusively on teaching within general medicine rounds. Thus, our findings may not be generalizable to other subspecialties. Fourth, attendings were selected through a nonexhaustive method, increasing the potential for selection bias. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Former-learner responses were subject to recall bias. Finally, the study design is susceptible to observer bias. Attempts to reduce this included the diversity of the observers (ie, both a clinician and a nonclinician, the latter of whom was unfamiliar with medical education) and review of the data and coding by multiple research team members to ensure validity. Although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team attempted to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Limitations notwithstanding, we believe that our multisite study is important given the longstanding imperative to improve patient-physician interactions. We found empirical support for behaviors proposed by Branch and colleagues² and Kahn¹² in order to enhance these relationships. While others have studied attendings and their current learners,²² we add to the literature by also examining former learners’ perspectives on how the attendings’ teaching and role-modeling have created and sustained a lasting impact. The key findings of our national, qualitative study (care for the patient’s well-being, consideration of the “big picture,” and respect for the patient) can be readily adopted and honed by physicians to improve their interactions with hospitalized patients.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Veterans Affairs.

Funding

Dr. Saint provided funding for this study using a University of Michigan endowment.

Disclosure

The authors declare no conflicts of interest.

Approximately a century ago, Francis Peabody taught that “the secret of the care of the patient is in caring for the patient.”¹ His advice remains true today. Despite the advent of novel diagnostic tests, technologically sophisticated interventional procedures, and life-saving medications, perhaps the most important skill a bedside clinician can use is the ability to connect with patients.

The literature on patient-physician interaction is vast^2-11 and generally indicates that exemplary bedside clinicians are able to interact well with patients by being competent, trustworthy, personable, empathetic, and effective communicators. “Etiquette-based medicine,” first proposed by Kahn,¹² emphasizes the importance of certain behaviors from physicians, such as introducing yourself and explaining your role, shaking hands, sitting down when speaking to patients, and asking open-ended questions.

Yet, improving patient-physician interactions remains necessary. A recent systematic review reported that almost half of the reviewed studies on the patient-physician relationship published between 2000 and 2014 conveyed the idea that the patient-physician relationship is deteriorating.¹³

As part of a broader study to understand the behaviors and approaches of exemplary inpatient attending physicians,^14-16 we examined how 12 carefully selected physicians interacted with their patients during inpatient teaching rounds.

Overview

We conducted a multisite study using an exploratory, qualitative approach to inquiry, which has been described previously.^14-16 Our primary purpose was to study the attributes and behaviors of outstanding general medicine attendings in the setting of inpatient rounds. The focus of this article is on the attendings’ interactions with patients.

We used a modified snowball sampling approach¹⁷ to identify 12 exemplary physicians. First, we contacted individuals throughout the United States who were known to the principal investigator (S.S.) and asked for suggestions of excellent clinician educators (also referred to as attendings) for potential inclusion in the study. In addition to these personal contacts, other individuals unknown to the investigative team were contacted and asked to provide suggestions for attendings to include in the study. Specifically, the US News & World Report 2015 Top Medical Schools: Research Rankings,¹⁸ which are widely used to represent the best U.S. hospitals, were reviewed in an effort to identify attendings from a broad range of medical schools. Using this list, we identified other medical schools that were in the top 25 and were not already represented. We contacted the division chiefs of general internal (or hospital) medicine, chairs and chiefs of departments of internal medicine, and internal medicine residency program directors from these medical schools and asked for recommendations of attendings from both within and outside their institutions whom they considered to be great inpatient teachers.

This sampling method resulted in 59 potential participants. An internet search was conducted on each potential participant to obtain further information about the individuals and their institutions. Both personal characteristics (medical education, training, and educational awards) and organizational characteristics (geographic location, hospital size and affiliation, and patient population) were considered so that a variety of organizations and backgrounds were represented. Through this process, the list was narrowed to 16 attendings who were contacted to participate in the study, of which 12 agreed. The number of attendings examined was appropriate because saturation of metathemes can occur in as little as 6 interviews, and data saturation occurs at 12 interviews.¹⁹ The participants were asked to provide a list of their current learners (ie, residents and medical students) and 6 to 10 former learners to contact for interviews and focus groups.

Data Collection

Observations

Two researchers conducted the one-day site visits. One was a physician (S.S.) and the other a medical anthropologist (M.H.), and both have extensive experience in qualitative methods. The only exception was the site visit at the principal investigator’s own institution, which was conducted by the medical anthropologist and a nonpracticing physician who was unknown to the participants. The team structure varied slightly among different institutions but in general was composed of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Each site visit began with observing the attendings (n = 12) and current learners (n = 57) on morning rounds, which included their interactions with patients. These observations lasted approximately 2 to 3 hours. The observers took handwritten field notes, paying particular attention to group interactions, teaching approaches, and patient interactions. The observers stood outside the medical team circle and remained silent during rounds so as to be unobtrusive to the teams’ discussions. The observers discussed and compared their notes after each site visit.

Interviews and Focus Groups

The research team also conducted individual, semistructured interviews with the attendings (n = 12), focus groups with their current teams (n = 46), and interviews or focus groups with their former learners (n = 26). Current learners were asked open-ended questions about their roles on the teams, their opinions of the attendings, and the care the attendings provide to their patients. Because they were observed during rounds, the researchers asked for clarification about specific interactions observed during the teaching rounds. Depending on availability and location, former learners either participated in in-person focus groups or interviews on the day of the site visit, or in a later telephone interview. All interviews and focus groups were audio recorded and transcribed.

This study was deemed to be exempt from regulation by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could refuse to answer any question.

Data Analysis

Data were analyzed using a thematic analysis approach,²⁰ which involves reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. The patterns are then grouped into themes to help further explain the findings.²¹ The research team members (S.S. and M.H.) met after the first site visit and developed initial ideas about meanings and possible patterns. One team member (M.H.) read all the transcripts from the site visit and, based on the data, developed a codebook to be used for this study. This process was repeated after every site visit, and the coding definitions were refined as necessary. All transcripts were reviewed to apply any new codes when they developed. NVivo^® 10 software (QSR International, Melbourne, Australia) was used to assist with the qualitative data analysis.

To ensure consistency and identify relationships between codes, code reports listing all the data linked to a specific code were generated after all the field notes and transcripts were coded. Once verified, codes were grouped based on similarities and relationships into prominent themes related to physician-patient interactions by 2 team members (S.S. and M.H.), though all members reviewed them and concurred.

Care for the Patient’s Well-Being

The attendings we observed appeared to openly care for their patients’ well-being and were focused on the patients’ wants and needs. We noted that attendings were generally very attentive to the patients’ comfort. For example, we observed one attending sending the senior resident to find the patient’s nurse in order to obtain additional pain medications. The attending said to the patient several times, “I’m sorry you’re in so much pain.” When the team was leaving, she asked the intern to stay with the patient until the medications had been administered.

Consideration of the “Big Picture”

Our exemplary attendings kept the “big picture” (that is, the patient’s overall medical and social needs) in clear focus. They behaved in a way to ensure that the patients understood the key points of their care and explained so the patients and families could understand. A current learner said, “[The attending] really makes sure that the patient understands what’s going on. And she always asks them, ‘What do you understand, what do you know, how can we fill in any blanks?’ And that makes the patient really involved in their own care, which I think is important.” This reflection was supported by direct observations. Attendings posed the following questions at the conclusion of patient interactions: “Tell me what you know.” “Tell me what our plan is.” “What did the lung doctors tell you yesterday?” These questions, which have been termed “teach-back” and are crucial for health literacy, were not meant to quiz the patient but rather to ensure the patient and family understood the plan.

We noticed that the attendings effectively explained clinical details and the plan of care to the patient while avoiding medical jargon. The following is an example of one interaction with a patient: “You threw up and created a tear in the food tube. Air got from that into the middle of the chest, not into the lungs. Air isn’t normally there. If it is just air, the body will reabsorb [it]... But we worry about bacteria getting in with the air. We need to figure out if it is an infection. We’re still trying to figure it out. Hang in there with us.” One learner commented, “… since we do bedside presentations, he has a great way of translating our gibberish, basically, to real language the patient understands.”

Finally, the attendings anticipated what patients would need in the outpatient setting. We observed that attendings stressed what the next steps would be during transitions of care. As one learner put it, “But he also thinks ahead; what do they need as an outpatient?” Another current learner commented on how another attending always asked about the social situations of his patients stating, “And then there is the social part of it. So, he is very much interested [in] where do they live? What is their support system? So, I think it has been a very holistic approach to patient care.”

Respect for the Patient

The attendings we observed were steadfastly respectful toward patients. As one attending told us, “The patient’s room is sacred space, and it’s a privilege for us to be there. And if we don’t earn that privilege, then we don’t get to go there.” We observed that the attendings generally referred to the patient as Mr. or Ms. (last name) rather than the patient’s first name unless the patient insisted. We also noticed that many of the attendings would introduce the team members to the patients or ask each member to introduce himself or herself. They also tended to leave the room and patient the way they were found, for example, by pushing the patient’s bedside table so that it was back within his or her reach or placing socks back onto the patient’s feet.

We noted that many of our attendings used appropriate humor with patients and families. As one learner explained, “I think Dr. [attending] makes most of our patients laugh during rounds. I don’t know if you noticed, but he really puts a smile on their face[s] whenever he walks in. … Maybe it would catch them off guard the first day, but after that, they are so happy to see him.”

Finally, we noticed that several of our attendings made sure to meet the patient at eye level during discussions by either kneeling or sitting on a chair. One of the attendings put it this way: “That’s a horrible power dynamic when you’re an inpatient and you’re sick and someone’s standing over you telling you things, and I like to be able to make eye contact with people, and often times that requires me to kneel down or to sit on a stool or to sit on the bed. … I feel like you’re able to connect with the people in a much better way…” Learners viewed this behavior favorably. As one told us, “[The attending] gets down to their level and makes sure that all of their questions are answered. So that is one thing that other attendings don’t necessarily do.”

In our national, qualitative study of 12 exemplary attending physicians, we found that these clinicians generally exhibited the following behaviors with patients. First, they were personable and caring and made significant attempts to connect with their patients. This occasionally took the form of using touch to comfort patients. Second, they tended to seek the “big picture” and tried to understand what patients would need upon hospital discharge. They communicated plans clearly to patients and families and inquired if those plans were understood. Finally, they showed respect toward their patients without fail. Such respect took many forms but included leaving the patient and room exactly as they were found and speaking with patients at eye level.

Our findings are largely consistent with other key studies in this field. Not surprisingly, the attendings we observed adhered to the major suggestions that Branch and colleagues² put forth more than 15 years ago to improve the teaching of the humanistic dimension of the patient-physician relationship. Examples include greeting the patient, introducing team members and explaining each person’s role, asking open-ended questions, providing patient education, placing oneself at the same level as the patient, using appropriate touch, and being respectful. Weissmann et al.²² also found similar themes in their study of teaching physicians at 4 universities from 2003 to 2004. In that study, role-modeling was the primary method used by physician educators to teach the humanistic aspects of medical care, including nonverbal communication (eg, touch and eye contact), demonstration of respect, and building a personal connection with the patients.²²In a focus group-based study performed at a teaching hospital in Boston, Ramani and Orlander²³ concluded that both participating teachers and learners considered the patient’s bedside as a valuable venue to learn humanistic skills. Unfortunately, they also noted that there has been a decline in bedside teaching related to various factors, including documentation requirements and electronic medical records.²³ Our attendings all demonstrated the value of teaching at a patient’s bedside. Not only could physical examination skills be demonstrated but role-modeling of interpersonal skills could be observed by learners.

Block and colleagues²⁴ observed 29 interns in 732 patient encounters in 2 Baltimore training programs using Kahn’s “etiquette-based medicine” behaviors as a guide.¹² They found that interns introduced themselves 40% of the time, explained their role 37% of the time, touched patients on 65% of visits (including as part of the physical examination), asked open-ended questions 75% of the time, and sat down with patients during only 9% of visits.²⁴ Tackett et al.⁷ observed 24 hospitalists who collectively cared for 226 unique patients in 3 Baltimore-area hospitals. They found that each of the following behaviors was performed less than 30% of the time: explains role in care, shakes hand, and sits down.⁷ However, our attendings appeared to adhere to these behaviors to a much higher extent, though we did not quantify the interactions. This lends support to the notion that effective patient-physician interactions are the foundation of great teaching.

The attendings we observed (most of whom are inpatient based) tended to the contextual issues of the patients, such as their home environments and social support. Our exemplary physicians did what they could to ensure that patients received the appropriate follow-up care upon discharge.

Our study has important limitations. First, it was conducted in a limited number of US hospitals. The institutions represented were generally large, research-intensive, academic medical centers. Therefore, our findings may not apply to settings that are different from the hospitals studied. Second, our study included only 12 attendings and their learners, which may also limit the study’s generalizability. Third, we focused exclusively on teaching within general medicine rounds. Thus, our findings may not be generalizable to other subspecialties. Fourth, attendings were selected through a nonexhaustive method, increasing the potential for selection bias. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Former-learner responses were subject to recall bias. Finally, the study design is susceptible to observer bias. Attempts to reduce this included the diversity of the observers (ie, both a clinician and a nonclinician, the latter of whom was unfamiliar with medical education) and review of the data and coding by multiple research team members to ensure validity. Although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team attempted to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Limitations notwithstanding, we believe that our multisite study is important given the longstanding imperative to improve patient-physician interactions. We found empirical support for behaviors proposed by Branch and colleagues² and Kahn¹² in order to enhance these relationships. While others have studied attendings and their current learners,²² we add to the literature by also examining former learners’ perspectives on how the attendings’ teaching and role-modeling have created and sustained a lasting impact. The key findings of our national, qualitative study (care for the patient’s well-being, consideration of the “big picture,” and respect for the patient) can be readily adopted and honed by physicians to improve their interactions with hospitalized patients.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Veterans Affairs.

Funding

Dr. Saint provided funding for this study using a University of Michigan endowment.

Disclosure

The authors declare no conflicts of interest.

Approximately a century ago, Francis Peabody taught that “the secret of the care of the patient is in caring for the patient.”¹ His advice remains true today. Despite the advent of novel diagnostic tests, technologically sophisticated interventional procedures, and life-saving medications, perhaps the most important skill a bedside clinician can use is the ability to connect with patients.

The literature on patient-physician interaction is vast^2-11 and generally indicates that exemplary bedside clinicians are able to interact well with patients by being competent, trustworthy, personable, empathetic, and effective communicators. “Etiquette-based medicine,” first proposed by Kahn,¹² emphasizes the importance of certain behaviors from physicians, such as introducing yourself and explaining your role, shaking hands, sitting down when speaking to patients, and asking open-ended questions.

Yet, improving patient-physician interactions remains necessary. A recent systematic review reported that almost half of the reviewed studies on the patient-physician relationship published between 2000 and 2014 conveyed the idea that the patient-physician relationship is deteriorating.¹³

As part of a broader study to understand the behaviors and approaches of exemplary inpatient attending physicians,^14-16 we examined how 12 carefully selected physicians interacted with their patients during inpatient teaching rounds.

Overview

We conducted a multisite study using an exploratory, qualitative approach to inquiry, which has been described previously.^14-16 Our primary purpose was to study the attributes and behaviors of outstanding general medicine attendings in the setting of inpatient rounds. The focus of this article is on the attendings’ interactions with patients.

We used a modified snowball sampling approach¹⁷ to identify 12 exemplary physicians. First, we contacted individuals throughout the United States who were known to the principal investigator (S.S.) and asked for suggestions of excellent clinician educators (also referred to as attendings) for potential inclusion in the study. In addition to these personal contacts, other individuals unknown to the investigative team were contacted and asked to provide suggestions for attendings to include in the study. Specifically, the US News & World Report 2015 Top Medical Schools: Research Rankings,¹⁸ which are widely used to represent the best U.S. hospitals, were reviewed in an effort to identify attendings from a broad range of medical schools. Using this list, we identified other medical schools that were in the top 25 and were not already represented. We contacted the division chiefs of general internal (or hospital) medicine, chairs and chiefs of departments of internal medicine, and internal medicine residency program directors from these medical schools and asked for recommendations of attendings from both within and outside their institutions whom they considered to be great inpatient teachers.

This sampling method resulted in 59 potential participants. An internet search was conducted on each potential participant to obtain further information about the individuals and their institutions. Both personal characteristics (medical education, training, and educational awards) and organizational characteristics (geographic location, hospital size and affiliation, and patient population) were considered so that a variety of organizations and backgrounds were represented. Through this process, the list was narrowed to 16 attendings who were contacted to participate in the study, of which 12 agreed. The number of attendings examined was appropriate because saturation of metathemes can occur in as little as 6 interviews, and data saturation occurs at 12 interviews.¹⁹ The participants were asked to provide a list of their current learners (ie, residents and medical students) and 6 to 10 former learners to contact for interviews and focus groups.

Data Collection

Observations

Two researchers conducted the one-day site visits. One was a physician (S.S.) and the other a medical anthropologist (M.H.), and both have extensive experience in qualitative methods. The only exception was the site visit at the principal investigator’s own institution, which was conducted by the medical anthropologist and a nonpracticing physician who was unknown to the participants. The team structure varied slightly among different institutions but in general was composed of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Each site visit began with observing the attendings (n = 12) and current learners (n = 57) on morning rounds, which included their interactions with patients. These observations lasted approximately 2 to 3 hours. The observers took handwritten field notes, paying particular attention to group interactions, teaching approaches, and patient interactions. The observers stood outside the medical team circle and remained silent during rounds so as to be unobtrusive to the teams’ discussions. The observers discussed and compared their notes after each site visit.

Interviews and Focus Groups

The research team also conducted individual, semistructured interviews with the attendings (n = 12), focus groups with their current teams (n = 46), and interviews or focus groups with their former learners (n = 26). Current learners were asked open-ended questions about their roles on the teams, their opinions of the attendings, and the care the attendings provide to their patients. Because they were observed during rounds, the researchers asked for clarification about specific interactions observed during the teaching rounds. Depending on availability and location, former learners either participated in in-person focus groups or interviews on the day of the site visit, or in a later telephone interview. All interviews and focus groups were audio recorded and transcribed.

This study was deemed to be exempt from regulation by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could refuse to answer any question.

Data Analysis

Data were analyzed using a thematic analysis approach,²⁰ which involves reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. The patterns are then grouped into themes to help further explain the findings.²¹ The research team members (S.S. and M.H.) met after the first site visit and developed initial ideas about meanings and possible patterns. One team member (M.H.) read all the transcripts from the site visit and, based on the data, developed a codebook to be used for this study. This process was repeated after every site visit, and the coding definitions were refined as necessary. All transcripts were reviewed to apply any new codes when they developed. NVivo^® 10 software (QSR International, Melbourne, Australia) was used to assist with the qualitative data analysis.

To ensure consistency and identify relationships between codes, code reports listing all the data linked to a specific code were generated after all the field notes and transcripts were coded. Once verified, codes were grouped based on similarities and relationships into prominent themes related to physician-patient interactions by 2 team members (S.S. and M.H.), though all members reviewed them and concurred.

Care for the Patient’s Well-Being

The attendings we observed appeared to openly care for their patients’ well-being and were focused on the patients’ wants and needs. We noted that attendings were generally very attentive to the patients’ comfort. For example, we observed one attending sending the senior resident to find the patient’s nurse in order to obtain additional pain medications. The attending said to the patient several times, “I’m sorry you’re in so much pain.” When the team was leaving, she asked the intern to stay with the patient until the medications had been administered.

Consideration of the “Big Picture”

Our exemplary attendings kept the “big picture” (that is, the patient’s overall medical and social needs) in clear focus. They behaved in a way to ensure that the patients understood the key points of their care and explained so the patients and families could understand. A current learner said, “[The attending] really makes sure that the patient understands what’s going on. And she always asks them, ‘What do you understand, what do you know, how can we fill in any blanks?’ And that makes the patient really involved in their own care, which I think is important.” This reflection was supported by direct observations. Attendings posed the following questions at the conclusion of patient interactions: “Tell me what you know.” “Tell me what our plan is.” “What did the lung doctors tell you yesterday?” These questions, which have been termed “teach-back” and are crucial for health literacy, were not meant to quiz the patient but rather to ensure the patient and family understood the plan.

We noticed that the attendings effectively explained clinical details and the plan of care to the patient while avoiding medical jargon. The following is an example of one interaction with a patient: “You threw up and created a tear in the food tube. Air got from that into the middle of the chest, not into the lungs. Air isn’t normally there. If it is just air, the body will reabsorb [it]... But we worry about bacteria getting in with the air. We need to figure out if it is an infection. We’re still trying to figure it out. Hang in there with us.” One learner commented, “… since we do bedside presentations, he has a great way of translating our gibberish, basically, to real language the patient understands.”

Finally, the attendings anticipated what patients would need in the outpatient setting. We observed that attendings stressed what the next steps would be during transitions of care. As one learner put it, “But he also thinks ahead; what do they need as an outpatient?” Another current learner commented on how another attending always asked about the social situations of his patients stating, “And then there is the social part of it. So, he is very much interested [in] where do they live? What is their support system? So, I think it has been a very holistic approach to patient care.”

Respect for the Patient

The attendings we observed were steadfastly respectful toward patients. As one attending told us, “The patient’s room is sacred space, and it’s a privilege for us to be there. And if we don’t earn that privilege, then we don’t get to go there.” We observed that the attendings generally referred to the patient as Mr. or Ms. (last name) rather than the patient’s first name unless the patient insisted. We also noticed that many of the attendings would introduce the team members to the patients or ask each member to introduce himself or herself. They also tended to leave the room and patient the way they were found, for example, by pushing the patient’s bedside table so that it was back within his or her reach or placing socks back onto the patient’s feet.

We noted that many of our attendings used appropriate humor with patients and families. As one learner explained, “I think Dr. [attending] makes most of our patients laugh during rounds. I don’t know if you noticed, but he really puts a smile on their face[s] whenever he walks in. … Maybe it would catch them off guard the first day, but after that, they are so happy to see him.”

Finally, we noticed that several of our attendings made sure to meet the patient at eye level during discussions by either kneeling or sitting on a chair. One of the attendings put it this way: “That’s a horrible power dynamic when you’re an inpatient and you’re sick and someone’s standing over you telling you things, and I like to be able to make eye contact with people, and often times that requires me to kneel down or to sit on a stool or to sit on the bed. … I feel like you’re able to connect with the people in a much better way…” Learners viewed this behavior favorably. As one told us, “[The attending] gets down to their level and makes sure that all of their questions are answered. So that is one thing that other attendings don’t necessarily do.”

In our national, qualitative study of 12 exemplary attending physicians, we found that these clinicians generally exhibited the following behaviors with patients. First, they were personable and caring and made significant attempts to connect with their patients. This occasionally took the form of using touch to comfort patients. Second, they tended to seek the “big picture” and tried to understand what patients would need upon hospital discharge. They communicated plans clearly to patients and families and inquired if those plans were understood. Finally, they showed respect toward their patients without fail. Such respect took many forms but included leaving the patient and room exactly as they were found and speaking with patients at eye level.

Our findings are largely consistent with other key studies in this field. Not surprisingly, the attendings we observed adhered to the major suggestions that Branch and colleagues² put forth more than 15 years ago to improve the teaching of the humanistic dimension of the patient-physician relationship. Examples include greeting the patient, introducing team members and explaining each person’s role, asking open-ended questions, providing patient education, placing oneself at the same level as the patient, using appropriate touch, and being respectful. Weissmann et al.²² also found similar themes in their study of teaching physicians at 4 universities from 2003 to 2004. In that study, role-modeling was the primary method used by physician educators to teach the humanistic aspects of medical care, including nonverbal communication (eg, touch and eye contact), demonstration of respect, and building a personal connection with the patients.²²In a focus group-based study performed at a teaching hospital in Boston, Ramani and Orlander²³ concluded that both participating teachers and learners considered the patient’s bedside as a valuable venue to learn humanistic skills. Unfortunately, they also noted that there has been a decline in bedside teaching related to various factors, including documentation requirements and electronic medical records.²³ Our attendings all demonstrated the value of teaching at a patient’s bedside. Not only could physical examination skills be demonstrated but role-modeling of interpersonal skills could be observed by learners.

Block and colleagues²⁴ observed 29 interns in 732 patient encounters in 2 Baltimore training programs using Kahn’s “etiquette-based medicine” behaviors as a guide.¹² They found that interns introduced themselves 40% of the time, explained their role 37% of the time, touched patients on 65% of visits (including as part of the physical examination), asked open-ended questions 75% of the time, and sat down with patients during only 9% of visits.²⁴ Tackett et al.⁷ observed 24 hospitalists who collectively cared for 226 unique patients in 3 Baltimore-area hospitals. They found that each of the following behaviors was performed less than 30% of the time: explains role in care, shakes hand, and sits down.⁷ However, our attendings appeared to adhere to these behaviors to a much higher extent, though we did not quantify the interactions. This lends support to the notion that effective patient-physician interactions are the foundation of great teaching.

The attendings we observed (most of whom are inpatient based) tended to the contextual issues of the patients, such as their home environments and social support. Our exemplary physicians did what they could to ensure that patients received the appropriate follow-up care upon discharge.

Our study has important limitations. First, it was conducted in a limited number of US hospitals. The institutions represented were generally large, research-intensive, academic medical centers. Therefore, our findings may not apply to settings that are different from the hospitals studied. Second, our study included only 12 attendings and their learners, which may also limit the study’s generalizability. Third, we focused exclusively on teaching within general medicine rounds. Thus, our findings may not be generalizable to other subspecialties. Fourth, attendings were selected through a nonexhaustive method, increasing the potential for selection bias. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Former-learner responses were subject to recall bias. Finally, the study design is susceptible to observer bias. Attempts to reduce this included the diversity of the observers (ie, both a clinician and a nonclinician, the latter of whom was unfamiliar with medical education) and review of the data and coding by multiple research team members to ensure validity. Although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team attempted to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Limitations notwithstanding, we believe that our multisite study is important given the longstanding imperative to improve patient-physician interactions. We found empirical support for behaviors proposed by Branch and colleagues² and Kahn¹² in order to enhance these relationships. While others have studied attendings and their current learners,²² we add to the literature by also examining former learners’ perspectives on how the attendings’ teaching and role-modeling have created and sustained a lasting impact. The key findings of our national, qualitative study (care for the patient’s well-being, consideration of the “big picture,” and respect for the patient) can be readily adopted and honed by physicians to improve their interactions with hospitalized patients.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Veterans Affairs.

Funding

Dr. Saint provided funding for this study using a University of Michigan endowment.

Disclosure

The authors declare no conflicts of interest.

Clinician educators face numerous obstacles to their joint mission of facilitating learning while also ensuring high-quality and patient-centered care. Time constraints, including the institution of house officer duty hour limitations,¹ shorter lengths of stay for hospitalized patients,² and competing career responsibilities, combine to create a dynamic learning environment. Additionally, clinician educators must balance the autonomy of their learners with the safety of their patients. They must teach to multiple learning levels and work collaboratively with multiple disciplines to foster an effective team-based approach to patient care. Yet, many clinician educators have no formal training in pedagogical methods.³ Such challenges necessitate increased attention to the work of excellent clinician educators and their respective teaching approaches.

Many studies of clinical teaching rely primarily on survey data of attributes of good clinical teachers.^3-7 While some studies have incorporated direct observations of teaching^8,9 or interviews with clinician educators or learners,^10,11 few have incorporated multiple perspectives from the current team and from former learners in order to provide a comprehensive picture of team-based learning.¹²

The goal of this study was to gain a thorough understanding, through multiple perspectives, of the techniques and behaviors used by exemplary educators within actual clinical environments. We studied attitudes, behaviors, and approaches of 12 such inpatient clinician educators.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. This approach was used to study the techniques and behaviors of excellent attendings during inpatient general medicine rounds. A modified snowball sampling approach¹³ was used, meaning individuals known to one member of the research team (SS) were initially contacted and asked to identify clinician educators (also referred to as attendings) for potential inclusion in the study. In an effort to identify attendings from a broad range of medical schools, the “2015 U.S. News and World Report Top Medical Schools: Research” rankings¹⁴ were also reviewed, with priority given to the top 25, as these are widely used to represent the best US hospitals. In an attempt to invite attendings from diverse institutions, additional medical schools not in the top 25 as well as historically black medical schools were also included. Division chiefs and chairs of internal medicine and/or directors of internal medicine residency programs at these schools were contacted and asked for recommendations of attendings, both within and outside their institutions, who they considered to be great inpatient teachers. In addition, key experts who have won teaching awards or were known to be specialists in the field of medical education were asked to nominate one or two other outstanding attendings.

By using this sampling method, 59 potential participants were identified. An internet search was conducted to obtain information about the potential participants and their institutions. Organizational characteristics such as geographic location, hospital size and affiliation, and patient population, as well as individual characteristics such as gender, medical education and training, and educational awards received were considered so that a diversity of organizations and backgrounds was represented. The list was narrowed down to 16 attendings who were contacted via e-mail and asked to participate. Interested participants were asked for a list of their current team members and 6 to 10 former learners to contact for interviews and focus groups. Former learners were included in an effort to better understand lasting effects on learners from their exemplary teaching attendings. A total of 12 attending physicians agreed to participate (Table 1). Literature on field methods has shown that 12 interviews are found to be adequate in accomplishing data saturation.¹⁵ Although 2 attendings were located at the same institution, we decided to include them given that both are recognized as master clinician educators and were each recommended by several individuals from various institutions. Hospitals were located throughout the US and included both university-affiliated hospitals and Veterans Affairs medical centers. Despite efforts to include physicians from historically black colleges and universities, only one attending was identified, and they declined the request to participate.

Data Collection

Observations. The one-day site visits were mainly conducted by two research team members, a physician (SS) and a medical anthropologist (MH), both of whom have extensive experience in qualitative methods. Teams were not uniform but were generally comprised of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Occasionally, a pharmacist, clinical assistant, or other health professional accompanied the team on rounds. Not infrequently, the bedside nurse would explicitly be included in the discussion regarding his or her specific patient. Each site visit began with observing attendings (N = 12) and current learners (N = 57) during rounds. Each research team member recorded their own observations via handwritten field notes, paying particular attention to group interactions, teaching approach, conversations occurring within and peripheral to the team, patient-team interactions, and the physical environment. By standing outside of the medical team circle and remaining silent during rounds, research team members remained unobtrusive to the discussion and process of rounds. Materials the attendings used during their teaching rounds were also documented and collected. Rounds generally lasted 2 to 3 hours. After each site visit, the research team met to compare and combine field notes.

Interviews and Focus Groups. The research team then conducted individual, semi-structured interviews with the attendings, focus groups with their current team (N = 46), and interviews or focus groups with their former learners (N = 26; Supplement 1). Eleven of the current team members observed during rounds were unable to participate in the focus groups due to clinical duties. Because the current learners who participated in the focus groups were also observed during rounds, the research team was able to ask them open-ended questions regarding teaching rounds and their roles as learners within this environment. Former learners who were still at the hospital participated in separate focus groups or interviews. Former learners who were no longer present at the hospital were contacted by telephone and individually interviewed by one research team member (MH). All interviews and focus groups were audio-recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a thematic analysis approach.¹⁶ Thematic analysis entails reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. Once patterns have been identified, they are grouped according to similarity into themes, which help to further explain the findings.¹⁷

After the first site visit was completed, the research team members that participated (SS and MH) met to develop initial ideas about meanings and possible patterns. All transcripts were read by one team member (MH) and, based on review of the data, codes were developed, defined, and documented in a codebook. This process was repeated after every site visit using the codebook to expand or combine codes and refine definitions as necessary. If a new code was added, the previously coded data were reviewed to apply the new code. NVivo® 10 software (QSR International; Melbourne, Australia) was used to manage the data.

Once all field notes and transcripts were coded (MH), the code reports, which list all data described within a specific code, were run to ensure consistency and identify relationships between codes. Once coding was verified, codes were grouped based on similarities and relationships into salient themes by 3 members of the research team (NH, MH, and SM). Themes, along with their supporting codes, were then further defined to understand how these attendings worked to facilitate excellent teaching in clinical settings.

The coded interview data and field notes were categorized into broad, overlapping themes. Three of these major themes include (1) fostering positive relationships, (2) patient-centered teaching, and (3) collaboration and coaching. Table 2 lists each theme, salient behaviors, examples, and selected quotes that further elucidate its meaning.

Fostering Positive Relationships

Attending physicians took observable steps to develop positive relationships with their team members, which in turn created a safe learning environment. For instance, attendings used learners’ first names, demonstrated interest in their well-being, deployed humor, and generally displayed informal actions—uncrossed arms, “fist bump” when recognizing learners’ success, standing outside the circle of team members and leaning in to listen—during learner interactions. Attendings also made it a priority to get to know individuals on a personal level. As one current learner put it, “He asks about where we are from. He will try to find some kind of connection that he can establish with not only each of the team members but also with each of the patients.”

Additionally, attendings built positive relationships with their learners by responding thoughtfully to their input, even when learners’ evaluations of patients required modification. In turn, learners reported feeling safe to ask questions, admit uncertainty, and respectfully disagree with their attendings. As one attending reflected, “If I can get them into a place where they feel like the learning environment is someplace where they can make a mistake and know that that mistake does not necessarily mean that it’s going to cost them in their evaluation part, then I feel like that’s why it’s important.”

To build rapport and create a safe learning environment, attendings used a number of strategies to position themselves as learners alongside their team members. For instance, attendings indicated that they wanted their ideas questioned because they saw it as an opportunity to learn. Moreover, in conversations with learners, attendings demonstrated humility, admitting when they did not know something. One former learner noted, “There have been times when he has asked [a] question…nobody knows and then he admits that he doesn’t know either. So everybody goes and looks it up…The whole thing turns out to be a fun learning experience.”

Attendings demonstrated respect for their team members’ time by reading about patients before rounds, identifying learning opportunities during rounds, and integrating teaching points into the daily work of patient care. Teaching was not relegated exclusively to the conference room or confined to the traditional “chalk talk” before or after rounds but rather was assimilated into daily workflow. They appeared to be responsive to the needs of individual patients and the team, which allowed attendings to both directly oversee their patients’ care and overcome the challenges of multiple competing demands for time. The importance of this approach was made clear by one current learner who stated “…she does prepare before, especially you know on call days, she does prepare for the new patients before coming in to staff, which is really appreciated… it saves a lot of time on rounds.”

Attendings also included other health professionals in team discussions. Attendings used many of the same relationship-building techniques with these professionals as they did with learners and patients. They consistently asked these professionals to provide insight and direction in patients’ plans of care. A former learner commented, “He always asks the [nurse] what is her impression of the patient...he truly values the [nurse’s] opinion of the patient.” One attending reiterated this approach, stating “I don’t want them to think that anything I have to say is more valuable than our pharmacist or the [nurse].”

Patient-Centered Teaching

Attending physicians modeled numerous teaching techniques that focused learning around the patient. Attendings knew their patients well through review of the medical records, discussion with the patient, and personal examination. This preparation allowed attendings to focus on key teaching points in the context of the patient. One former learner noted, “He tended to bring up a variety of things that really fit well into the clinical scenario. So whether that is talking about what is the differential for a new symptom that just came up for this patient or kind of here is a new paper talking about this condition or maybe some other pearl of physical exam for a patient that has a certain physical condition.”

Attendings served as effective role models by being directly involved in examining and talking with patients as well as demonstrating excellent physical examination and communication techniques. One current learner articulated the importance of learning these skills by observing them done well: “I think he teaches by example and by doing, again, those little things: being attentive to the patients and being very careful during exams…I think those are things that you teach people by doing them, not by saying you need to do this better during the patient encounter.”

Collaboration and Coaching

Attending physicians used varied collaboration and coaching techniques to facilitate learning across the entire care team. During rounds, attendings utilized visual aids to reinforce key concepts and simplify complex topics. They also collaborated by using discussion rather than lecture to engage with team members. For instance, attendings used Socratic questioning, asking questions that lead learners through critical thinking and allow them to solve problems themselves, to guide learners’ decision-making. One former learner reported, “He never gives you the answer, and he always asks your opinion; ‘So what are your thoughts on this?’”

Coaching for success, rather than directing the various team members, was emphasized. Attendings did not wish to be seen as the “leaders” of the team. During rounds, one attending was noted to explain his role in ensuring that the team was building connections with others: “When we have a bad outcome, if it feels like your soul has been ripped out, then you’ve done something right. You’ve made that connection with the patient. My job, as your coach, was to build communication between all of us so we feel vested in each other and our patients.”

Attendings also fostered clinical reasoning skills in their learners by encouraging them to verbalize their thought processes aloud in order to clarify and check for understanding. Attendings also placed emphasis not simply on memorizing content but rather prioritization of the patient’s problems and thinking step by step through individual medical problems. One current learner applauded an attending who could “come up with schematics of how to approach problems rather than feeding us factual information of this paper or this trial.”

Additionally, attendings facilitated learning across the entire care team by differentiating their teaching to meet the needs of multiple learning levels. While the entire team was explicitly included in the learning process, attendings encouraged learners to play various roles, execute tasks, and answer questions depending on their educational level. Attendings positioned learners as leaders of the team by allowing them to talk without interruption and by encouraging them to take ownership of their patients’ care. One former learner stated, “She set expectations…we would be the ones who would be running the team, that you know it would very much be our team and that she is there to advise us and provide supervision but also safety for the patients as well.”

This study reveals the complex ways effective attendings build rapport, create a safe learning environment, utilize patient-centered teaching strategies, and engage in collaboration and coaching with all members of the team. These findings provide a framework of shared themes and their salient behaviors that may influence the success of inpatient general medicine clinician educators (Table 3).

There is a broad and voluminous literature on the subject of outstanding clinical teaching characteristics, much of which has shaped various faculty development curricula for decades. This study sought not to identify novel approaches of inpatient teaching necessarily but rather to closely examine the techniques and behaviors of clinician educators identified as exemplary. The findings affirm and reinforce the numerous, well-documented lists of personal attributes, techniques, and behaviors that resonate with learners, including creating a positive environment, demonstrating enthusiasm and interest in the learner, reading facial expressions, being student-centered, maintaining a high level of clinical knowledge, and utilizing effective communication skills.^18-24 The strengths of this study lie within the nuanced and rich observations and discussions that move beyond learners’ Likert scale evaluations and responses.^3-7,12 Input was sought from multiple perspectives on the care team, which provided detail from key stakeholders. Out of these comprehensive data arose several conclusions that extend the research literature on medical education.

In their seminal review, Sutkin et al.¹⁸ demonstrate that two thirds of characteristics of outstanding clinical teachers are “noncognitive” and that, “Perhaps what makes a clinical educator truly great depends less on the acquisition of cognitive skills such as medical knowledge and formulating learning objectives, and more on inherent, relationship-based, noncognitive attributes. Whereas cognitive abilities generally involve skills that may be taught and learned, albeit with difficulty, noncognitive abilities represent personal attributes, such as relationship skills, personality types, and emotional states, which are more difficult to develop and teach.”¹⁸ Our study, thus, adds to the literature by (1) highlighting examples of techniques and behaviors that encompass the crucial “noncognitive” arena and (2) informing best practices in teaching clinical medicine, especially those that resonate with learners, for future faculty development.

The findings highlight the role that relationships play in the teaching and learning of team-based medicine. Building rapport and sustaining successful relationships are cornerstones of effective teaching.¹⁸ For the attendings in this study, this manifested in observable, tangible behaviors such as greeting others by name, joking, using physical touch, and actively involving all team members, regardless of role or level of education. Previous literature has highlighted the importance of showing interest in learners.^7,19,25-27 This study provides multiple and varied examples of ways in which interest might be displayed.

For patients, the critical role of relationships was evidenced through rapport building and attention to patients as people outside their acute hospitalization. For instance, attendings regularly put patients’ medical issues into context and anticipated future outpatient challenges. To the authors’ knowledge, previous scholarship has not significantly emphasized this form of contextualized medicine, which involves the mindful consideration of the ongoing needs patients may experience upon transitions of care.

Several participants highlighted humility as an important characteristic of effective clinician educators. Attendings recognized that the field produces more new knowledge than can possibly be assimilated and that uncertainty is a mainstay of modern medical care. Attendings frequently utilized self-deprecation to acknowledge doubt, a technique that created a collaborative environment in which learners also felt safe to ask questions. These findings support the viewpoints by Reilly and Beckman that humility and an appreciation for questions and push-back from learners encourage lifelong learning through role modeling.^19,23 In responding to the interviewer’s question “And what happens when [the attending] is wrong?” one learner simply stated, “He makes fun of himself.”

This study has several limitations. First, it was conducted in a limited number of US based healthcare systems. The majority of institutions represented were larger, research intensive hospitals. While these hospitals were purposefully selected to provide a range in geography, size, type, and access to resources, the findings may differ in other settings. Second, it was conducted with a limited number of attendings and learners, which may limit the study’s generalizability. However, enough interviews were conducted to reach data saturation.¹⁵ Because evidence for a causal relationship between quality teaching and student and patient outcomes is lacking,¹⁸ we must rely on imperfect proxies for teaching excellence, including awards and recognition. This study attempted to identify exemplary educators through various means, but it is recognized that bias is likely. Third, because attendings provided lists of former learners, selection and recall biases may have been introduced, as attendings may have more readily identified former learners with whom they formed strong relationships. Fourth, focus was placed exclusively on teaching and learning within general medicine rounds. This was because there would be ample opportunity for teaching on this service, the structure of the teams and the types of patients would be comparable across sites, and the principal investigator was also a general medicine attending and would have a frame of reference for these types of rounds. Due to this narrow focus, the findings may not be generalizable to other subspecialties. Fifth, attendings were selected through a nonexhaustive method. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Finally, although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team did attempt to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Using a combination of interviews, focus group discussions, and direct observation, we identified consistent techniques and behaviors of excellent teaching attendings during inpatient general medicine rounds. We hope that all levels of clinician educators may use them to elevate their own teaching.

Disclosure

Dr. Saint is on a medical advisory board of Doximity, a new social networking site for physicians, and receives an honorarium. He is also on the scientific advisory board of Jvion, a healthcare technology company. Drs. Houchens, Harrod, Moody, and Ms. Fowler have no conflicts of interest.

Clinician educators face numerous obstacles to their joint mission of facilitating learning while also ensuring high-quality and patient-centered care. Time constraints, including the institution of house officer duty hour limitations,¹ shorter lengths of stay for hospitalized patients,² and competing career responsibilities, combine to create a dynamic learning environment. Additionally, clinician educators must balance the autonomy of their learners with the safety of their patients. They must teach to multiple learning levels and work collaboratively with multiple disciplines to foster an effective team-based approach to patient care. Yet, many clinician educators have no formal training in pedagogical methods.³ Such challenges necessitate increased attention to the work of excellent clinician educators and their respective teaching approaches.

Many studies of clinical teaching rely primarily on survey data of attributes of good clinical teachers.^3-7 While some studies have incorporated direct observations of teaching^8,9 or interviews with clinician educators or learners,^10,11 few have incorporated multiple perspectives from the current team and from former learners in order to provide a comprehensive picture of team-based learning.¹²

The goal of this study was to gain a thorough understanding, through multiple perspectives, of the techniques and behaviors used by exemplary educators within actual clinical environments. We studied attitudes, behaviors, and approaches of 12 such inpatient clinician educators.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. This approach was used to study the techniques and behaviors of excellent attendings during inpatient general medicine rounds. A modified snowball sampling approach¹³ was used, meaning individuals known to one member of the research team (SS) were initially contacted and asked to identify clinician educators (also referred to as attendings) for potential inclusion in the study. In an effort to identify attendings from a broad range of medical schools, the “2015 U.S. News and World Report Top Medical Schools: Research” rankings¹⁴ were also reviewed, with priority given to the top 25, as these are widely used to represent the best US hospitals. In an attempt to invite attendings from diverse institutions, additional medical schools not in the top 25 as well as historically black medical schools were also included. Division chiefs and chairs of internal medicine and/or directors of internal medicine residency programs at these schools were contacted and asked for recommendations of attendings, both within and outside their institutions, who they considered to be great inpatient teachers. In addition, key experts who have won teaching awards or were known to be specialists in the field of medical education were asked to nominate one or two other outstanding attendings.

By using this sampling method, 59 potential participants were identified. An internet search was conducted to obtain information about the potential participants and their institutions. Organizational characteristics such as geographic location, hospital size and affiliation, and patient population, as well as individual characteristics such as gender, medical education and training, and educational awards received were considered so that a diversity of organizations and backgrounds was represented. The list was narrowed down to 16 attendings who were contacted via e-mail and asked to participate. Interested participants were asked for a list of their current team members and 6 to 10 former learners to contact for interviews and focus groups. Former learners were included in an effort to better understand lasting effects on learners from their exemplary teaching attendings. A total of 12 attending physicians agreed to participate (Table 1). Literature on field methods has shown that 12 interviews are found to be adequate in accomplishing data saturation.¹⁵ Although 2 attendings were located at the same institution, we decided to include them given that both are recognized as master clinician educators and were each recommended by several individuals from various institutions. Hospitals were located throughout the US and included both university-affiliated hospitals and Veterans Affairs medical centers. Despite efforts to include physicians from historically black colleges and universities, only one attending was identified, and they declined the request to participate.

Data Collection

Observations. The one-day site visits were mainly conducted by two research team members, a physician (SS) and a medical anthropologist (MH), both of whom have extensive experience in qualitative methods. Teams were not uniform but were generally comprised of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Occasionally, a pharmacist, clinical assistant, or other health professional accompanied the team on rounds. Not infrequently, the bedside nurse would explicitly be included in the discussion regarding his or her specific patient. Each site visit began with observing attendings (N = 12) and current learners (N = 57) during rounds. Each research team member recorded their own observations via handwritten field notes, paying particular attention to group interactions, teaching approach, conversations occurring within and peripheral to the team, patient-team interactions, and the physical environment. By standing outside of the medical team circle and remaining silent during rounds, research team members remained unobtrusive to the discussion and process of rounds. Materials the attendings used during their teaching rounds were also documented and collected. Rounds generally lasted 2 to 3 hours. After each site visit, the research team met to compare and combine field notes.

Interviews and Focus Groups. The research team then conducted individual, semi-structured interviews with the attendings, focus groups with their current team (N = 46), and interviews or focus groups with their former learners (N = 26; Supplement 1). Eleven of the current team members observed during rounds were unable to participate in the focus groups due to clinical duties. Because the current learners who participated in the focus groups were also observed during rounds, the research team was able to ask them open-ended questions regarding teaching rounds and their roles as learners within this environment. Former learners who were still at the hospital participated in separate focus groups or interviews. Former learners who were no longer present at the hospital were contacted by telephone and individually interviewed by one research team member (MH). All interviews and focus groups were audio-recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a thematic analysis approach.¹⁶ Thematic analysis entails reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. Once patterns have been identified, they are grouped according to similarity into themes, which help to further explain the findings.¹⁷

After the first site visit was completed, the research team members that participated (SS and MH) met to develop initial ideas about meanings and possible patterns. All transcripts were read by one team member (MH) and, based on review of the data, codes were developed, defined, and documented in a codebook. This process was repeated after every site visit using the codebook to expand or combine codes and refine definitions as necessary. If a new code was added, the previously coded data were reviewed to apply the new code. NVivo® 10 software (QSR International; Melbourne, Australia) was used to manage the data.

Once all field notes and transcripts were coded (MH), the code reports, which list all data described within a specific code, were run to ensure consistency and identify relationships between codes. Once coding was verified, codes were grouped based on similarities and relationships into salient themes by 3 members of the research team (NH, MH, and SM). Themes, along with their supporting codes, were then further defined to understand how these attendings worked to facilitate excellent teaching in clinical settings.

The coded interview data and field notes were categorized into broad, overlapping themes. Three of these major themes include (1) fostering positive relationships, (2) patient-centered teaching, and (3) collaboration and coaching. Table 2 lists each theme, salient behaviors, examples, and selected quotes that further elucidate its meaning.

Fostering Positive Relationships

Attending physicians took observable steps to develop positive relationships with their team members, which in turn created a safe learning environment. For instance, attendings used learners’ first names, demonstrated interest in their well-being, deployed humor, and generally displayed informal actions—uncrossed arms, “fist bump” when recognizing learners’ success, standing outside the circle of team members and leaning in to listen—during learner interactions. Attendings also made it a priority to get to know individuals on a personal level. As one current learner put it, “He asks about where we are from. He will try to find some kind of connection that he can establish with not only each of the team members but also with each of the patients.”

Additionally, attendings built positive relationships with their learners by responding thoughtfully to their input, even when learners’ evaluations of patients required modification. In turn, learners reported feeling safe to ask questions, admit uncertainty, and respectfully disagree with their attendings. As one attending reflected, “If I can get them into a place where they feel like the learning environment is someplace where they can make a mistake and know that that mistake does not necessarily mean that it’s going to cost them in their evaluation part, then I feel like that’s why it’s important.”

To build rapport and create a safe learning environment, attendings used a number of strategies to position themselves as learners alongside their team members. For instance, attendings indicated that they wanted their ideas questioned because they saw it as an opportunity to learn. Moreover, in conversations with learners, attendings demonstrated humility, admitting when they did not know something. One former learner noted, “There have been times when he has asked [a] question…nobody knows and then he admits that he doesn’t know either. So everybody goes and looks it up…The whole thing turns out to be a fun learning experience.”

Attendings demonstrated respect for their team members’ time by reading about patients before rounds, identifying learning opportunities during rounds, and integrating teaching points into the daily work of patient care. Teaching was not relegated exclusively to the conference room or confined to the traditional “chalk talk” before or after rounds but rather was assimilated into daily workflow. They appeared to be responsive to the needs of individual patients and the team, which allowed attendings to both directly oversee their patients’ care and overcome the challenges of multiple competing demands for time. The importance of this approach was made clear by one current learner who stated “…she does prepare before, especially you know on call days, she does prepare for the new patients before coming in to staff, which is really appreciated… it saves a lot of time on rounds.”

Attendings also included other health professionals in team discussions. Attendings used many of the same relationship-building techniques with these professionals as they did with learners and patients. They consistently asked these professionals to provide insight and direction in patients’ plans of care. A former learner commented, “He always asks the [nurse] what is her impression of the patient...he truly values the [nurse’s] opinion of the patient.” One attending reiterated this approach, stating “I don’t want them to think that anything I have to say is more valuable than our pharmacist or the [nurse].”

Patient-Centered Teaching

Attending physicians modeled numerous teaching techniques that focused learning around the patient. Attendings knew their patients well through review of the medical records, discussion with the patient, and personal examination. This preparation allowed attendings to focus on key teaching points in the context of the patient. One former learner noted, “He tended to bring up a variety of things that really fit well into the clinical scenario. So whether that is talking about what is the differential for a new symptom that just came up for this patient or kind of here is a new paper talking about this condition or maybe some other pearl of physical exam for a patient that has a certain physical condition.”

Attendings served as effective role models by being directly involved in examining and talking with patients as well as demonstrating excellent physical examination and communication techniques. One current learner articulated the importance of learning these skills by observing them done well: “I think he teaches by example and by doing, again, those little things: being attentive to the patients and being very careful during exams…I think those are things that you teach people by doing them, not by saying you need to do this better during the patient encounter.”

Collaboration and Coaching

Attending physicians used varied collaboration and coaching techniques to facilitate learning across the entire care team. During rounds, attendings utilized visual aids to reinforce key concepts and simplify complex topics. They also collaborated by using discussion rather than lecture to engage with team members. For instance, attendings used Socratic questioning, asking questions that lead learners through critical thinking and allow them to solve problems themselves, to guide learners’ decision-making. One former learner reported, “He never gives you the answer, and he always asks your opinion; ‘So what are your thoughts on this?’”

Coaching for success, rather than directing the various team members, was emphasized. Attendings did not wish to be seen as the “leaders” of the team. During rounds, one attending was noted to explain his role in ensuring that the team was building connections with others: “When we have a bad outcome, if it feels like your soul has been ripped out, then you’ve done something right. You’ve made that connection with the patient. My job, as your coach, was to build communication between all of us so we feel vested in each other and our patients.”

Attendings also fostered clinical reasoning skills in their learners by encouraging them to verbalize their thought processes aloud in order to clarify and check for understanding. Attendings also placed emphasis not simply on memorizing content but rather prioritization of the patient’s problems and thinking step by step through individual medical problems. One current learner applauded an attending who could “come up with schematics of how to approach problems rather than feeding us factual information of this paper or this trial.”

Additionally, attendings facilitated learning across the entire care team by differentiating their teaching to meet the needs of multiple learning levels. While the entire team was explicitly included in the learning process, attendings encouraged learners to play various roles, execute tasks, and answer questions depending on their educational level. Attendings positioned learners as leaders of the team by allowing them to talk without interruption and by encouraging them to take ownership of their patients’ care. One former learner stated, “She set expectations…we would be the ones who would be running the team, that you know it would very much be our team and that she is there to advise us and provide supervision but also safety for the patients as well.”

This study reveals the complex ways effective attendings build rapport, create a safe learning environment, utilize patient-centered teaching strategies, and engage in collaboration and coaching with all members of the team. These findings provide a framework of shared themes and their salient behaviors that may influence the success of inpatient general medicine clinician educators (Table 3).

There is a broad and voluminous literature on the subject of outstanding clinical teaching characteristics, much of which has shaped various faculty development curricula for decades. This study sought not to identify novel approaches of inpatient teaching necessarily but rather to closely examine the techniques and behaviors of clinician educators identified as exemplary. The findings affirm and reinforce the numerous, well-documented lists of personal attributes, techniques, and behaviors that resonate with learners, including creating a positive environment, demonstrating enthusiasm and interest in the learner, reading facial expressions, being student-centered, maintaining a high level of clinical knowledge, and utilizing effective communication skills.^18-24 The strengths of this study lie within the nuanced and rich observations and discussions that move beyond learners’ Likert scale evaluations and responses.^3-7,12 Input was sought from multiple perspectives on the care team, which provided detail from key stakeholders. Out of these comprehensive data arose several conclusions that extend the research literature on medical education.

In their seminal review, Sutkin et al.¹⁸ demonstrate that two thirds of characteristics of outstanding clinical teachers are “noncognitive” and that, “Perhaps what makes a clinical educator truly great depends less on the acquisition of cognitive skills such as medical knowledge and formulating learning objectives, and more on inherent, relationship-based, noncognitive attributes. Whereas cognitive abilities generally involve skills that may be taught and learned, albeit with difficulty, noncognitive abilities represent personal attributes, such as relationship skills, personality types, and emotional states, which are more difficult to develop and teach.”¹⁸ Our study, thus, adds to the literature by (1) highlighting examples of techniques and behaviors that encompass the crucial “noncognitive” arena and (2) informing best practices in teaching clinical medicine, especially those that resonate with learners, for future faculty development.

The findings highlight the role that relationships play in the teaching and learning of team-based medicine. Building rapport and sustaining successful relationships are cornerstones of effective teaching.¹⁸ For the attendings in this study, this manifested in observable, tangible behaviors such as greeting others by name, joking, using physical touch, and actively involving all team members, regardless of role or level of education. Previous literature has highlighted the importance of showing interest in learners.^7,19,25-27 This study provides multiple and varied examples of ways in which interest might be displayed.

For patients, the critical role of relationships was evidenced through rapport building and attention to patients as people outside their acute hospitalization. For instance, attendings regularly put patients’ medical issues into context and anticipated future outpatient challenges. To the authors’ knowledge, previous scholarship has not significantly emphasized this form of contextualized medicine, which involves the mindful consideration of the ongoing needs patients may experience upon transitions of care.

Several participants highlighted humility as an important characteristic of effective clinician educators. Attendings recognized that the field produces more new knowledge than can possibly be assimilated and that uncertainty is a mainstay of modern medical care. Attendings frequently utilized self-deprecation to acknowledge doubt, a technique that created a collaborative environment in which learners also felt safe to ask questions. These findings support the viewpoints by Reilly and Beckman that humility and an appreciation for questions and push-back from learners encourage lifelong learning through role modeling.^19,23 In responding to the interviewer’s question “And what happens when [the attending] is wrong?” one learner simply stated, “He makes fun of himself.”

This study has several limitations. First, it was conducted in a limited number of US based healthcare systems. The majority of institutions represented were larger, research intensive hospitals. While these hospitals were purposefully selected to provide a range in geography, size, type, and access to resources, the findings may differ in other settings. Second, it was conducted with a limited number of attendings and learners, which may limit the study’s generalizability. However, enough interviews were conducted to reach data saturation.¹⁵ Because evidence for a causal relationship between quality teaching and student and patient outcomes is lacking,¹⁸ we must rely on imperfect proxies for teaching excellence, including awards and recognition. This study attempted to identify exemplary educators through various means, but it is recognized that bias is likely. Third, because attendings provided lists of former learners, selection and recall biases may have been introduced, as attendings may have more readily identified former learners with whom they formed strong relationships. Fourth, focus was placed exclusively on teaching and learning within general medicine rounds. This was because there would be ample opportunity for teaching on this service, the structure of the teams and the types of patients would be comparable across sites, and the principal investigator was also a general medicine attending and would have a frame of reference for these types of rounds. Due to this narrow focus, the findings may not be generalizable to other subspecialties. Fifth, attendings were selected through a nonexhaustive method. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Finally, although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team did attempt to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Using a combination of interviews, focus group discussions, and direct observation, we identified consistent techniques and behaviors of excellent teaching attendings during inpatient general medicine rounds. We hope that all levels of clinician educators may use them to elevate their own teaching.

Disclosure

Dr. Saint is on a medical advisory board of Doximity, a new social networking site for physicians, and receives an honorarium. He is also on the scientific advisory board of Jvion, a healthcare technology company. Drs. Houchens, Harrod, Moody, and Ms. Fowler have no conflicts of interest.

Clinician educators face numerous obstacles to their joint mission of facilitating learning while also ensuring high-quality and patient-centered care. Time constraints, including the institution of house officer duty hour limitations,¹ shorter lengths of stay for hospitalized patients,² and competing career responsibilities, combine to create a dynamic learning environment. Additionally, clinician educators must balance the autonomy of their learners with the safety of their patients. They must teach to multiple learning levels and work collaboratively with multiple disciplines to foster an effective team-based approach to patient care. Yet, many clinician educators have no formal training in pedagogical methods.³ Such challenges necessitate increased attention to the work of excellent clinician educators and their respective teaching approaches.

Many studies of clinical teaching rely primarily on survey data of attributes of good clinical teachers.^3-7 While some studies have incorporated direct observations of teaching^8,9 or interviews with clinician educators or learners,^10,11 few have incorporated multiple perspectives from the current team and from former learners in order to provide a comprehensive picture of team-based learning.¹²

The goal of this study was to gain a thorough understanding, through multiple perspectives, of the techniques and behaviors used by exemplary educators within actual clinical environments. We studied attitudes, behaviors, and approaches of 12 such inpatient clinician educators.

Study Design and Sampling

This was a multisite study using an exploratory qualitative approach to inquiry. This approach was used to study the techniques and behaviors of excellent attendings during inpatient general medicine rounds. A modified snowball sampling approach¹³ was used, meaning individuals known to one member of the research team (SS) were initially contacted and asked to identify clinician educators (also referred to as attendings) for potential inclusion in the study. In an effort to identify attendings from a broad range of medical schools, the “2015 U.S. News and World Report Top Medical Schools: Research” rankings¹⁴ were also reviewed, with priority given to the top 25, as these are widely used to represent the best US hospitals. In an attempt to invite attendings from diverse institutions, additional medical schools not in the top 25 as well as historically black medical schools were also included. Division chiefs and chairs of internal medicine and/or directors of internal medicine residency programs at these schools were contacted and asked for recommendations of attendings, both within and outside their institutions, who they considered to be great inpatient teachers. In addition, key experts who have won teaching awards or were known to be specialists in the field of medical education were asked to nominate one or two other outstanding attendings.

By using this sampling method, 59 potential participants were identified. An internet search was conducted to obtain information about the potential participants and their institutions. Organizational characteristics such as geographic location, hospital size and affiliation, and patient population, as well as individual characteristics such as gender, medical education and training, and educational awards received were considered so that a diversity of organizations and backgrounds was represented. The list was narrowed down to 16 attendings who were contacted via e-mail and asked to participate. Interested participants were asked for a list of their current team members and 6 to 10 former learners to contact for interviews and focus groups. Former learners were included in an effort to better understand lasting effects on learners from their exemplary teaching attendings. A total of 12 attending physicians agreed to participate (Table 1). Literature on field methods has shown that 12 interviews are found to be adequate in accomplishing data saturation.¹⁵ Although 2 attendings were located at the same institution, we decided to include them given that both are recognized as master clinician educators and were each recommended by several individuals from various institutions. Hospitals were located throughout the US and included both university-affiliated hospitals and Veterans Affairs medical centers. Despite efforts to include physicians from historically black colleges and universities, only one attending was identified, and they declined the request to participate.

Data Collection

Observations. The one-day site visits were mainly conducted by two research team members, a physician (SS) and a medical anthropologist (MH), both of whom have extensive experience in qualitative methods. Teams were not uniform but were generally comprised of 1 attending, 1 senior medical resident, 1 to 2 interns, and approximately 2 medical students. Occasionally, a pharmacist, clinical assistant, or other health professional accompanied the team on rounds. Not infrequently, the bedside nurse would explicitly be included in the discussion regarding his or her specific patient. Each site visit began with observing attendings (N = 12) and current learners (N = 57) during rounds. Each research team member recorded their own observations via handwritten field notes, paying particular attention to group interactions, teaching approach, conversations occurring within and peripheral to the team, patient-team interactions, and the physical environment. By standing outside of the medical team circle and remaining silent during rounds, research team members remained unobtrusive to the discussion and process of rounds. Materials the attendings used during their teaching rounds were also documented and collected. Rounds generally lasted 2 to 3 hours. After each site visit, the research team met to compare and combine field notes.

Interviews and Focus Groups. The research team then conducted individual, semi-structured interviews with the attendings, focus groups with their current team (N = 46), and interviews or focus groups with their former learners (N = 26; Supplement 1). Eleven of the current team members observed during rounds were unable to participate in the focus groups due to clinical duties. Because the current learners who participated in the focus groups were also observed during rounds, the research team was able to ask them open-ended questions regarding teaching rounds and their roles as learners within this environment. Former learners who were still at the hospital participated in separate focus groups or interviews. Former learners who were no longer present at the hospital were contacted by telephone and individually interviewed by one research team member (MH). All interviews and focus groups were audio-recorded and transcribed.

This study was determined to be exempt by the University of Michigan Institutional Review Board. All participants were informed that their participation was completely voluntary and that they could terminate their involvement at any time.

Data Analysis

Data were analyzed using a thematic analysis approach.¹⁶ Thematic analysis entails reading through the data to identify patterns (and create codes) that relate to behaviors, experiences, meanings, and activities. Once patterns have been identified, they are grouped according to similarity into themes, which help to further explain the findings.¹⁷

After the first site visit was completed, the research team members that participated (SS and MH) met to develop initial ideas about meanings and possible patterns. All transcripts were read by one team member (MH) and, based on review of the data, codes were developed, defined, and documented in a codebook. This process was repeated after every site visit using the codebook to expand or combine codes and refine definitions as necessary. If a new code was added, the previously coded data were reviewed to apply the new code. NVivo® 10 software (QSR International; Melbourne, Australia) was used to manage the data.

Once all field notes and transcripts were coded (MH), the code reports, which list all data described within a specific code, were run to ensure consistency and identify relationships between codes. Once coding was verified, codes were grouped based on similarities and relationships into salient themes by 3 members of the research team (NH, MH, and SM). Themes, along with their supporting codes, were then further defined to understand how these attendings worked to facilitate excellent teaching in clinical settings.

The coded interview data and field notes were categorized into broad, overlapping themes. Three of these major themes include (1) fostering positive relationships, (2) patient-centered teaching, and (3) collaboration and coaching. Table 2 lists each theme, salient behaviors, examples, and selected quotes that further elucidate its meaning.

Fostering Positive Relationships

Attending physicians took observable steps to develop positive relationships with their team members, which in turn created a safe learning environment. For instance, attendings used learners’ first names, demonstrated interest in their well-being, deployed humor, and generally displayed informal actions—uncrossed arms, “fist bump” when recognizing learners’ success, standing outside the circle of team members and leaning in to listen—during learner interactions. Attendings also made it a priority to get to know individuals on a personal level. As one current learner put it, “He asks about where we are from. He will try to find some kind of connection that he can establish with not only each of the team members but also with each of the patients.”

Additionally, attendings built positive relationships with their learners by responding thoughtfully to their input, even when learners’ evaluations of patients required modification. In turn, learners reported feeling safe to ask questions, admit uncertainty, and respectfully disagree with their attendings. As one attending reflected, “If I can get them into a place where they feel like the learning environment is someplace where they can make a mistake and know that that mistake does not necessarily mean that it’s going to cost them in their evaluation part, then I feel like that’s why it’s important.”

To build rapport and create a safe learning environment, attendings used a number of strategies to position themselves as learners alongside their team members. For instance, attendings indicated that they wanted their ideas questioned because they saw it as an opportunity to learn. Moreover, in conversations with learners, attendings demonstrated humility, admitting when they did not know something. One former learner noted, “There have been times when he has asked [a] question…nobody knows and then he admits that he doesn’t know either. So everybody goes and looks it up…The whole thing turns out to be a fun learning experience.”

Attendings demonstrated respect for their team members’ time by reading about patients before rounds, identifying learning opportunities during rounds, and integrating teaching points into the daily work of patient care. Teaching was not relegated exclusively to the conference room or confined to the traditional “chalk talk” before or after rounds but rather was assimilated into daily workflow. They appeared to be responsive to the needs of individual patients and the team, which allowed attendings to both directly oversee their patients’ care and overcome the challenges of multiple competing demands for time. The importance of this approach was made clear by one current learner who stated “…she does prepare before, especially you know on call days, she does prepare for the new patients before coming in to staff, which is really appreciated… it saves a lot of time on rounds.”

Attendings also included other health professionals in team discussions. Attendings used many of the same relationship-building techniques with these professionals as they did with learners and patients. They consistently asked these professionals to provide insight and direction in patients’ plans of care. A former learner commented, “He always asks the [nurse] what is her impression of the patient...he truly values the [nurse’s] opinion of the patient.” One attending reiterated this approach, stating “I don’t want them to think that anything I have to say is more valuable than our pharmacist or the [nurse].”

Patient-Centered Teaching

Attending physicians modeled numerous teaching techniques that focused learning around the patient. Attendings knew their patients well through review of the medical records, discussion with the patient, and personal examination. This preparation allowed attendings to focus on key teaching points in the context of the patient. One former learner noted, “He tended to bring up a variety of things that really fit well into the clinical scenario. So whether that is talking about what is the differential for a new symptom that just came up for this patient or kind of here is a new paper talking about this condition or maybe some other pearl of physical exam for a patient that has a certain physical condition.”

Attendings served as effective role models by being directly involved in examining and talking with patients as well as demonstrating excellent physical examination and communication techniques. One current learner articulated the importance of learning these skills by observing them done well: “I think he teaches by example and by doing, again, those little things: being attentive to the patients and being very careful during exams…I think those are things that you teach people by doing them, not by saying you need to do this better during the patient encounter.”

Collaboration and Coaching

Attending physicians used varied collaboration and coaching techniques to facilitate learning across the entire care team. During rounds, attendings utilized visual aids to reinforce key concepts and simplify complex topics. They also collaborated by using discussion rather than lecture to engage with team members. For instance, attendings used Socratic questioning, asking questions that lead learners through critical thinking and allow them to solve problems themselves, to guide learners’ decision-making. One former learner reported, “He never gives you the answer, and he always asks your opinion; ‘So what are your thoughts on this?’”

Coaching for success, rather than directing the various team members, was emphasized. Attendings did not wish to be seen as the “leaders” of the team. During rounds, one attending was noted to explain his role in ensuring that the team was building connections with others: “When we have a bad outcome, if it feels like your soul has been ripped out, then you’ve done something right. You’ve made that connection with the patient. My job, as your coach, was to build communication between all of us so we feel vested in each other and our patients.”

Attendings also fostered clinical reasoning skills in their learners by encouraging them to verbalize their thought processes aloud in order to clarify and check for understanding. Attendings also placed emphasis not simply on memorizing content but rather prioritization of the patient’s problems and thinking step by step through individual medical problems. One current learner applauded an attending who could “come up with schematics of how to approach problems rather than feeding us factual information of this paper or this trial.”

Additionally, attendings facilitated learning across the entire care team by differentiating their teaching to meet the needs of multiple learning levels. While the entire team was explicitly included in the learning process, attendings encouraged learners to play various roles, execute tasks, and answer questions depending on their educational level. Attendings positioned learners as leaders of the team by allowing them to talk without interruption and by encouraging them to take ownership of their patients’ care. One former learner stated, “She set expectations…we would be the ones who would be running the team, that you know it would very much be our team and that she is there to advise us and provide supervision but also safety for the patients as well.”

This study reveals the complex ways effective attendings build rapport, create a safe learning environment, utilize patient-centered teaching strategies, and engage in collaboration and coaching with all members of the team. These findings provide a framework of shared themes and their salient behaviors that may influence the success of inpatient general medicine clinician educators (Table 3).

There is a broad and voluminous literature on the subject of outstanding clinical teaching characteristics, much of which has shaped various faculty development curricula for decades. This study sought not to identify novel approaches of inpatient teaching necessarily but rather to closely examine the techniques and behaviors of clinician educators identified as exemplary. The findings affirm and reinforce the numerous, well-documented lists of personal attributes, techniques, and behaviors that resonate with learners, including creating a positive environment, demonstrating enthusiasm and interest in the learner, reading facial expressions, being student-centered, maintaining a high level of clinical knowledge, and utilizing effective communication skills.^18-24 The strengths of this study lie within the nuanced and rich observations and discussions that move beyond learners’ Likert scale evaluations and responses.^3-7,12 Input was sought from multiple perspectives on the care team, which provided detail from key stakeholders. Out of these comprehensive data arose several conclusions that extend the research literature on medical education.

In their seminal review, Sutkin et al.¹⁸ demonstrate that two thirds of characteristics of outstanding clinical teachers are “noncognitive” and that, “Perhaps what makes a clinical educator truly great depends less on the acquisition of cognitive skills such as medical knowledge and formulating learning objectives, and more on inherent, relationship-based, noncognitive attributes. Whereas cognitive abilities generally involve skills that may be taught and learned, albeit with difficulty, noncognitive abilities represent personal attributes, such as relationship skills, personality types, and emotional states, which are more difficult to develop and teach.”¹⁸ Our study, thus, adds to the literature by (1) highlighting examples of techniques and behaviors that encompass the crucial “noncognitive” arena and (2) informing best practices in teaching clinical medicine, especially those that resonate with learners, for future faculty development.

The findings highlight the role that relationships play in the teaching and learning of team-based medicine. Building rapport and sustaining successful relationships are cornerstones of effective teaching.¹⁸ For the attendings in this study, this manifested in observable, tangible behaviors such as greeting others by name, joking, using physical touch, and actively involving all team members, regardless of role or level of education. Previous literature has highlighted the importance of showing interest in learners.^7,19,25-27 This study provides multiple and varied examples of ways in which interest might be displayed.

For patients, the critical role of relationships was evidenced through rapport building and attention to patients as people outside their acute hospitalization. For instance, attendings regularly put patients’ medical issues into context and anticipated future outpatient challenges. To the authors’ knowledge, previous scholarship has not significantly emphasized this form of contextualized medicine, which involves the mindful consideration of the ongoing needs patients may experience upon transitions of care.

Several participants highlighted humility as an important characteristic of effective clinician educators. Attendings recognized that the field produces more new knowledge than can possibly be assimilated and that uncertainty is a mainstay of modern medical care. Attendings frequently utilized self-deprecation to acknowledge doubt, a technique that created a collaborative environment in which learners also felt safe to ask questions. These findings support the viewpoints by Reilly and Beckman that humility and an appreciation for questions and push-back from learners encourage lifelong learning through role modeling.^19,23 In responding to the interviewer’s question “And what happens when [the attending] is wrong?” one learner simply stated, “He makes fun of himself.”

This study has several limitations. First, it was conducted in a limited number of US based healthcare systems. The majority of institutions represented were larger, research intensive hospitals. While these hospitals were purposefully selected to provide a range in geography, size, type, and access to resources, the findings may differ in other settings. Second, it was conducted with a limited number of attendings and learners, which may limit the study’s generalizability. However, enough interviews were conducted to reach data saturation.¹⁵ Because evidence for a causal relationship between quality teaching and student and patient outcomes is lacking,¹⁸ we must rely on imperfect proxies for teaching excellence, including awards and recognition. This study attempted to identify exemplary educators through various means, but it is recognized that bias is likely. Third, because attendings provided lists of former learners, selection and recall biases may have been introduced, as attendings may have more readily identified former learners with whom they formed strong relationships. Fourth, focus was placed exclusively on teaching and learning within general medicine rounds. This was because there would be ample opportunity for teaching on this service, the structure of the teams and the types of patients would be comparable across sites, and the principal investigator was also a general medicine attending and would have a frame of reference for these types of rounds. Due to this narrow focus, the findings may not be generalizable to other subspecialties. Fifth, attendings were selected through a nonexhaustive method. However, the multisite design, the modified snowball sampling, and the inclusion of several types of institutions in the final participant pool introduced diversity to the final list. Finally, although we cannot discount the potential role of a Hawthorne effect on our data collection, the research team did attempt to mitigate this by standing apart from the care teams and remaining unobtrusive during observations.

Using a combination of interviews, focus group discussions, and direct observation, we identified consistent techniques and behaviors of excellent teaching attendings during inpatient general medicine rounds. We hope that all levels of clinician educators may use them to elevate their own teaching.

Disclosure

Dr. Saint is on a medical advisory board of Doximity, a new social networking site for physicians, and receives an honorarium. He is also on the scientific advisory board of Jvion, a healthcare technology company. Drs. Houchens, Harrod, Moody, and Ms. Fowler have no conflicts of interest.