March 25, 2024
HOMERuN Collaborative: Learners on Direct Care Service Focus Groups
The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.
Organizers and Facilitators: Catherine Callister, Gopi Astik, Anne Linker, Angela Alday, Matt Atkins, Sara Westergaard, Amy Yu, Marisha Burden

Background: As academic hospitalist groups grow their clinical footprint, there are increasingly less opportunities for traditional teaching time. One approach to providing additional teaching opportunities for hospitalists and more educational opportunities for learners is to place learners on direct care services, where an attending is providing direct care to patients on the services while working with a learner. However, there may be potential challenges with these models given the tension between direct care duties and time for teaching when on these services.

On our 2/9 call, we discussed hospitalists' experience of providing a direct care on a service and teaching a learner at the same time, including the challenges, benefits, and what approaches could be implemented to improve the experience, below are our results.
Barriers of teaching while on a direct care service
  • High census/clinical load is the biggest challenge: Teaching while also trying to meet metrics such as discharge is hard. At the same time, most direct care services do not have space for teaching.
  • Efficiency problems get exacerbated: Work styles on direct teaching services are different, and in order to teach and do clinical work, hospitalists end up staying much later. Faculty who struggle with efficiency struggle more on a direct care teaching team.
  • Expectations matter: Faculty prefer traditional teaching services over direct care teaching. If direct care teaching is spread across multiple services, keeping teaching goals consistent is difficult.
  • The needs of learners have impact on work in subtle ways: Earlier learners (especially if they can't put in own orders) can delay patient care.
"Constraints on 'do more, do it faster, and do it better,' does not always lend itself to slowing down and taking the time needed for a learner."
Facilitators of teaching while on a direct care service
  • Most important factor for success is an appropriate census: The cap on a direct care service needs to match the ability of the learner on service. Earlier learners require a lower cap.
  • Dedicated teachers matter: Having excellent teachers for these services or having passionate faculty self-select matters, they are excited about teaching and don't mind an occasional longer day.
  • Learners love the one-on-one mentorship: These services are often a favorite for medical students as they get to do more, get more direct observation and feedback, and get all of the teaching adjusted to their level.
  • Use existing structures for support: Being able to send the learners to traditional didactics (i.e., noon conference) gives the hospitalist some solo time to get work done. Services like admitting/swing can help offload task switching for the hospitalist.
"The medical students really enjoy having that direct connection with an attending, in fact, a couple of medical students didn't realize hospital medicine was a career and said: 'Wow, I like this! I want to look into doing this.'"
Ideal direct care service
  • Create a workable census: Census must be adjusted to the level of leaner, financially "it can't be RVU based, it has to live outside the productivity model."
  • Faculty development on didactics: Teach faculty that teaching around the point of care (i.e., feedback on a med rec or a code status discussion) instead of extended lectures may be appropriate for this service.
  • Be mindful of expectations and scheduling: Ensure there are clearly defined roles and responsibilities for each level of learner, stagger the starting day for hospitalists and learners.
  • Consider a different rounding format:  
  • Discovery rounds: See patients together in the morning-gives opportunities for attending to observe learner doing history & physical.
  • Attending transcribes in the room: Attending writes notes in the room while student does history/physical.
  • Rounding time: Rounding time is not limited by residency program constraints, can be more flexible, do orders as you go, teach the med student at the bedside.
"The most important thing is that the workload of the hospitalist is adjusted for the level of the learners so that you can give them the time and teaching that they need."
How learners have been incorporated onto direct care teaching services
Key Takeaways
  1. Clinical workloads matter — they impact the ability to teach. 
  2. Learner types matter — some learners facilitate the clinical work while others may make that more challenging.
  3. Synergize teaching with the setting — sometimes this may be on the job training in the clinical realm or taking advantage of naturally existing educational offerings (i.e., noon conferences).
Our next meeting will be on May 10, 2024.
Image Attributions: Vector images from
Check out the HOMERuN website for more information.
If you would like to join the HOMERuN Collaborative calls, please reach out to [email protected].