Hospitalist grand rounds: Vision to reality

Instituting a grand rounds specifically for the hospitalist service.

Medical grand rounds have long held a prominent place in medical education, both for trainees and practicing clinicians. Often said to have begun in 1889 at The Johns Hopkins Hospital in Baltimore with Sir William Osler, the fundamental structure of grand rounds has undergone considerable change, but continues as a tradition of academic medicine (11. Osler W. The natural method of teaching the subject of medicine. JAMA 1901;36:1673-9., 22. Bogdonoff MD. A brief look at medical grand rounds. Pharos Alpha Omega Alpha Honor Society. 1982;42:16-8., 33. Altman LK. Socratic dialogue gives way to PowerPoint. New York Times. Dec. 12, 2006. Accessed at on July 30, 2014.).

However, with medicine's growing complexities and time constraints, it has become increasingly difficult for hospitalists to carve out time for education, and many institutions have seen a decrease in attendance at their general medical grand rounds (44. Mueller PS, Segovis CM, Litin SC, Habermann TM, Parrino TA. Current status of medical grand rounds in departments of medicine at US medical schools. Mayo Clin Proc. 2006;81:313-21. [PMID: 16529134], 55. Wachter B. Why I refused to let our medical grand rounds die off. Wachter's World Blog. Jan. 11, 2010. Accessed at on July 30, 2014., 66. Hebert RS, Wright SM. Re-examining the value of medical grand rounds. Acad Med. 2003;78:1248-52. [PMID: 14660428]). As a result, while general medical grand rounds still hold a place in academic centers, many institutions have developed robust specialty-specific grand rounds.

We've recently initiated this for hospital medicine at our institutions and found both challenges and benefits. Oregon Health & Science University (OHSU) is a large academic center in Portland and the only medical school in Oregon. It has a division of hospital medicine that is composed of approximately 25 hospitalists, not all of whom are currently involved in teaching roles. Physically connected by a sky bridge, the neighboring Portland VA Medical Center (PVAMC) has a group of approximately 20 hospitalists, many of whom divide their time between teaching and non-teaching services. While both sites are immersed in an academic environment and exposed to various educational formats including weekly medicine grand rounds, there were previously no dedicated educational conferences for hospitalists.

We formed a steering committee of 4 members (2 hospitalists from each division) who selected and invited a panel of speakers known for their teaching skills or expertise. The speakers were asked to prepare an approximately 35- to 45-minute talk and encouraged to include audience engagement. Speakers included hospitalists within the group who had a particular interest, subspecialists, or non-clinical personnel. Hospitalist grand rounds was scheduled monthly, alternating between sites, and was advertised via email reminders to both hospitalist groups, medical chief residents, outpatient attendings who rotated on the inpatient wards, and department chairs. The talks were held in the afternoon on days that were not typical switch days for hospitalist shift change. The audience varied from 5-15 attendees per month. A wide variety of topics was covered, including:

  • Pulmonary embolus: challenging the conventional wisdoms and algorithms
  • Clinical problem-solving case
  • Rapid fire: anemia in the hospital
  • Prevention of AF-related stroke: current therapies and controversies
  • Malpractice attorney presentation with Q and A
  • Case-based, interactive teaching session in a workshop format on hospital-based chronic wound care, with specific wound care products and devices being demonstrated
  • The in-hospital DNR order: Can it cause harm?
  • Readmissions, re-engineering and reform: transitions of care in today's health systems
  • Team-based interventions to prevent falls in the hospital

Several challenges were found in implementing this curriculum. First, many non-teaching hospitalists work block schedules, and it was difficult to find a time when physicians who were off could come in and when those who were on service had a relatively quiet time in their workflow. In addition, many people in the group had recurring meetings that interfered with attending grand rounds. There also was initially no funding for these grand rounds to allow offering of CME, though eventually both the OHSU and PVAMC hospitalist divisions were able to provide funding for CME credits.

More important, there were several benefits to hospital medicine grand rounds that quickly became apparent. First, division-specific grand rounds can break down the silos that naturally develop between clinicians working in different clinical contexts. This is true between physicians and nurses or advanced practice providers, who were among the speakers chosen. Second, hospitalist grand rounds can lead to a sense of community among hospitalists, as well as between hospitalists and specialists who are invited to speak; this is especially true when the grand rounds alternate between sites. This sense of shared purpose allows a freer exchange of dialogue between the hospitalist group and the speaker. Finally, hospitalist grand rounds offer an opportunity to hone presentations skills and an outlet for academic accomplishments in a much less intimidating format than a conference presentation.

Hospital medicine is relatively new but plays a major role in clinical care, teaching, and academic endeavors at many institutions. As part of the development of professional identity, it is important to have dedicated teaching conferences for hospitalists, and hospitalist grand rounds are a useful format. While it involves some work and creativity, this activity can easily be started at any hospitalist program, regardless of size or funding, and we would encourage its adoption.