"teaching cases" vs. "non-teaching cases"

[(Pants)^2]

In my hospital we just instituted a policy whereby the admitting medical resident will decide if a pt is to be followed by a wards team.

A "teaching case" is any patient that needs close watching, is atypical in any way, is worrisome for whatever reason, or is otherwise sick. ~85% admissions

A "non teaching case" is a case where the pt is being admitted for placement (social admit), a straight forward low prob chest pain, or a straight forward cellulitis (there are others, but these are the common ones)

So, for a simple chest pain rule out MI, a pt with <3 cardiac risk factors, no changes on EKG, 1st set CK/Trops neg, and currently CP free would not have a resident do the H&P or be followed on the wards.

Since we get ~5 of these pts per call, the policy is meant to lessen the workload on residents during call. This is to counter the rampant abuse by attending physicians in using residents to do the H&P and orders so that they are not bothered at night. These "non teaching case" patients are usually discharged the next day.

Needless to say, I've been getting in many an arguments over the past few days with my superiors...

Anyone's residency have a similar policy?

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[elwademd]

In my hospital we just instituted a policy whereby the admitting medical resident will decide if a pt is to be followed by a wards team.

A "teaching case" is any patient that needs close watching, is atypical in any way, is worrisome for whatever reason, or is otherwise sick. ~85% admissions

A "non teaching case" is a case where the pt is being admitted for placement (social admit), a straight forward low prob chest pain, or a straight forward cellulitis (there are others, but these are the common ones)

So, for a simple chest pain rule out MI, a pt with <3 cardiac risk factors, no changes on EKG, 1st set CK/Trops neg, and currently CP free would not have a resident do the H&P or be followed on the wards.

Since we get ~5 of these pts per call, the policy is meant to lessen the workload on residents during call. This is to counter the rampant abuse by attending physicians in using residents to do the H&P and orders so that they are not bothered at night. These "non teaching case" patients are usually discharged the next day.

Needless to say, I've been getting in many an arguments over the past few days with my superiors...

Anyone's residency have a similar policy?

very interesting.

i suppose that with that policy, there will always be a battle between the residents and the attendings, as it's in the residents' best interest for the case to be "non-teaching" and the attendings' best interest for the case to be "teaching."

and in the end, i suppose the attendings can butter up the residents and say that it's all about the patient, and the residents provide better care because, well, the residents are there in the hospital!

if the senior resident is a good resident and all about patient care, then i suppose the policy works. it's when the resident doesn't care so much, or maybe just isn't that bright that the policy begins to fall apart. but i suppose at the same time, if a resident's not that bright, the policy is irrelevant as the patient's care may suffer regardless!

i suppose another argument against the policy is that you learn by doing, and if you haven't seen it, you won't learn it. if an intern never sees a "straightforward" cellulitis case, then how will he/she know what to do as a resident? as an attending in private practice?

idk. but i think the heart of the matter is residency overwork, and i think that it's great that your program is trying to figure out a solution. whether or not this is the way to do it is debatable. i see both the pros and the cons, and i'm a resident as well, so i'd like to see more pros from others out there! lol.

yesterday morning, an attending that trained in the 70s was telling a few interns that we complain to much, because when he trained they admitted 20-25 patients a night, on icu they were q 2 for 6 weeks, otherwise they were q 3; they had 5 days off a year; and there was no such thing as calling in sick, because you'd have to prove you were sick, which meant coming in to see the program director! needless to say, i'm not surprised that you're catching some flack on the issue from your superiors.

 

[(Pants)^2]

Thanks for the nice reply.

If there is any doubt about whether a pt should be a "teaching case", I always error on the side of safety and admit the pt. This is a new system and we are being very meticulous in who we say "no, I won't do that admission" to. All we need is one bad outcome and an attending will cry "see! I told you so!".

Also, if a previously "non teaching case" develops something new while in the hospital, it automatically becomes a "teaching case". So, if that low prob chest pain comes back with + trops, then that pt is automatically picked up by a wards team.

Since this policy has been instituted, our residents have been unfailingly correct regarding in whom to admit. Our census is also running ~ 5 pts less post call.

 

[Gastrapathy]

In my hospital we just instituted a policy whereby the admitting medical resident will decide if a pt is to be followed by a wards team.

A "teaching case" is any patient that needs close watching, is atypical in any way, is worrisome for whatever reason, or is otherwise sick. ~85% admissions

A "non teaching case" is a case where the pt is being admitted for placement (social admit), a straight forward low prob chest pain, or a straight forward cellulitis (there are others, but these are the common ones)

So, for a simple chest pain rule out MI, a pt with <3 cardiac risk factors, no changes on EKG, 1st set CK/Trops neg, and currently CP free would not have a resident do the H&P or be followed on the wards.

Since we get ~5 of these pts per call, the policy is meant to lessen the workload on residents during call. This is to counter the rampant abuse by attending physicians in using residents to do the H&P and orders so that they are not bothered at night. These "non teaching case" patients are usually discharged the next day.

Needless to say, I've been getting in many an arguments over the past few days with my superiors...

Anyone's residency have a similar policy?

Seen something similar. In this case, though, the teams always capped and so the teaching/nonteaching distinction was designed to keep the teams from filling up with easy patients and leaving the hard ones for the hospitalist.

 

[gutonc]

One of our 2 hospitals is instituting a non-teaching, hospitalist service this year. They have chosen not to split patients in a "learning" vs "non-learning" way, rather, random chance. The reason for this is that if you dump all the ROMIs and COPD exacerbations on the hospitalists, you'll have a heck of a time keeping people for more than a year or so as they'll get so annoyed and depressed. The other reason is that, at least in theory, every case is a teaching case. And at least until December, not every intern is burned out on these cases. By making the patient assignment random (I think the first 8-10 patients of the day go to short then long-call and then they alternate b/w house staff and hospitalists but I may be wrong...it's a new system) there will hopefully be less of the animosity b/w house staff and hospitalists that you talk about.

I don't know that there's a perfect system for this unless you have the on-call attending (or chief resident or ER attending) vet each case for who should take it. Where I went to med school there was a 3rd year IM resident in the ED 24/7 whose job it was to evaluate all patients who the ER was thinking of admitting and determining whether they should even be admitted, ICU/tele/floor and whether they would go to house staff, a weird semi-teaching service run by hospitalists w/ IMG students but no house staff or the non-teaching service. I don't think that was the best system b/c as the resident, you'll always protect your own and admit the cool cases to the house staff.

I think the random assignment may be the best of a bunch of bad choices b/c, at least in theory, everyone should end up getting a mix of the lame ROMIs and COPD exacerbations, the good bread and butter stuff and the cool zebras. I would suggest that in order to know when you're really seeing an MI, you probably need to admit a few folks w/ costochondritis, etc.

I'll be curious to see how our system works IRL or if they've already changed it by the time I have my first ward month this year (not until Oct).

 

[carrigallen]

I wouldn't like the system the OP describes, especially if you are capping when on-call. It basically means your census fills up with barnacles that the non-teaching team doesn't want to touch. The main purpose of non-teaching is to off-load some of the tedious and redundant work of the resident. ROMIs are easy and keep your census low because they go home in 20 hrs; you don't even have to dictate them.

In general having a healthy balance of routine cases (like ROMI) keeps your census moving. Filling your census up with rocks, trainwrecks, and dispo nightmares is a recipe for pain and pandamonium. I think non-teaching is best suited for patients who aren't going anywhere but have no acute medical issues (ie nursing home placement).

 

[(Pants)^2]

I wouldn't like the system the OP describes, especially if you are capping when on-call..

If you are routinely capping, then yeah, this would not be a good system because you will fill your list with train wrecks. If you are not routinely capping, then this system works well because it would be an absolute reduction in your total # cases. At least, that is what I am expereincing.