Observationists: A Unique Model of Training at a Tertiary Academic Center

A 2003 study reported that nearly 20% of US hospitals had established observation units, with an additional 11% planning to open one.¹ Observation units have grown in prominence as a crucial component of hospital operations. Historically, they have been staffed by emergency medicine physicians. Internal medicine programs now are beginning to recognize the important role these units can play in more effectively preparing the next generation of internists to face challenges in the field. In addition to improved patient satisfaction and high-quality care in a cost-effective manner, observation medicine has the potential to be a rewarding educational experience for residents.

With the advent of hospital medicine, there is an increasing role for the hospitalist to provide clinical care in the observation unit and to participate in observation unit leadership.²

Our institution recognized this paradigm shift and created an innovative model that educates the next generation of physicians on the concept of observation medicine to prepare future observationists. Advocate Christ Medical Center is a 700-bed community teaching medical center that trains more than 400 residents, 600 medical students, and 800 nursing students. Its Level 1 trauma center sees more than 115 000 emergency department visits annually. There are 2 dedicated observation units with 35 beds situated close to the emergency department that are staffed by internal medicine residents, who are supervised by teaching faculty year round.

Our program pioneered an innovative observation medicine curriculum for internal medicine residents, which aims to strengthen the confidence of residents in managing observation patients, including increased understanding of regulatory requirements, billing, coding, and discharge coordination. The rotation reinforces residents' sense of autonomy, and provides a rich source of scholarly activity in quality improvement.

The challenge was to develop an observation medicine curriculum geared toward internal medicine residents. Despite a paucity of literature, we were able to create an innovative curriculum to prepare the next generation of observationists, and to move observation medicine into the arena of hospital medicine.

To assess acceptance of the curriculum by trainees, we surveyed residents within 6 months of the rotation. The response was encouraging, with more than 90% (29 of 32) strongly agreeing that this rotation was beneficial to their learning and prepared them for the real world of medicine.³ Since then, the internal medicine residents have initiated and implemented multiple quality improvement projects that have been presented at various journals and published.^4–6

In our model, residents are exposed to a blend of clinical care, fiscal responsibility, and patient accountability. We feel the experience is a win-win proposition for all stakeholders—hospitals, physicians, residents, and most important, patients. Additionally, our institutional data show that resident-run units are educationally, clinically, and financially beneficial.

Teaching and exposure to observation medicine is not currently a mainstay for internal medicine residency programs. We focused on describing our observation medicine rotation, which also exposes residents to quality metrics and quality improvement, and expands the scope of resident education. We have yet to find a similar internal medicine teaching observation unit in an academic center across the country.