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Profile: For this physician, teaching is the perfect antidote to exhaustion

October 2005

Published in the October 2005 issue of Today’s Hospitalist

As all hospitalists know, treating very sick inpatients all day, every day is a recipe for exhaustion. An antidote, according to Mark Kulaga, MD, associate program director for internal medicine at Norwalk Hospital in Norwalk, Conn., is teaching.

Hospitalists, contends Dr. Kulaga, not only have innumerable opportunities to teach in the course of their jobs, but as several published studies have shown, they are particularly good at it.

During his keynote presentation at the Fall 2005 Hospitalist CME Series in Houston on Nov. 7, Dr. Kulaga plans to explore the many ways that teaching can enhance the career of hospitalists. One of his key messages is when he talks about teaching, he does not mean just teaching medical students, interns and residents at academic medical centers.

As a clinician-educator at a community hospital in Norwalk, Conn., Dr. Kulaga likes to think of himself supervising “learners at all stages,” a group that includes about 40 internal medicine residents a year and 10 to 15 medical students at any given time. But he says that all hospitalists have even broader opportunities to get involved with education.

“There are opportunities for all of us to teach,” Dr. Kulaga explains. “Sometimes we aren’t even aware of them, but the people around us “whether it’s residents, nurses or patients “want information from us. And it is something I truly believe will make our lives better and make our careers sustainable.”

How residents rate hospitalists

Dr. Kulaga was the lead author of one of the key studies to show that hospitalists make good teachers. The study, which was published in the April 2004 issue of the Journal of General Internal Medicine, examined the impact of Norwalk Hospital’s decision to hire “hospitalist clinician-educators” not only on length-of-stay and costs of care, but also on resident education.

Researchers found that 97 percent of Norwalk Hospital’s internal medicine residents reported that having hospitalists as teachers improved formal and informal education, including bedside rounds, attending rounds and didactic conferences.

Studies at other academic medical centers have similarly found that residents appreciate having hospitalists as teachers. Researchers from Emory in Atlanta, for example, found that housestaff and medical students considered hospitalists to be more effective teachers than subspecialists.

Dr. Kulaga, who is an instructor of medicine at Yale University School of Medicine, will present similar data at the meeting, some of which also has shown that hospitalists are particularly good at providing feedback to housestaff and emphasizing cost-effectiveness. “I think there are probably enough data now” to make the case that hospitalists are good teachers, he explains.

Teaching at nonacademic centers

The next phase for hospitalists-as-educators is to look at their effectiveness teaching nurses and patients. While not every hospitalist teaches medical students and residents, everyone has ancillary staff and patients to educate. And in Dr. Kulaga’s view, at least, being a doctor means being a teacher.

While a number of studies have examined patient satisfaction with hospitalists, he explains, hospitalists’ involvement in “and their effect on “patient education is yet unstudied.

“But educating patients is one of the most important things that we do,” he explains. “It certainly helps the people around us, whether they are residents, nurses or patients. It also helps to increase our visibility within the hospital and helps to add more value to the hospital when we do it.”

Dr. Kulaga is quick to acknowledge that it may not be easy to add or maintain a focus on education in a health care business climate that stresses productivity and billable services.

“Teaching is a wonderful thing, but it doesn’t pay anything per se,” he says. “There is no reimbursement.”

A challenge for hospitalists, therefore, is to convince hospital administrators that teaching is a value-added service and should be supported. This is a particular problem in hospitals that do not consider themselves teaching hospitals.

Overcoming barriers

Even in teaching hospitals, he adds, changes in work hours for residents are adding new costs and challenges for the educational mission. At Norwalk Hospital, for instance, Dr. Kulaga says, the duty-hours rules that took effect in July 2003 mean new work schedules for the hospitalist clinician-educators and rapid growth in the size of the program.

In 1999, when Dr. Kulaga started his job there, Norwalk Hospital had two hospitalist clinician-educators on staff. Today there are six, and Dr. Kulaga says the hospital is considering hiring more soon.

Other barriers that may make it difficult for hospitalists to get more involved in teaching, he says, include the lack of time, particularly where there is such pressure to see more and more patients, and lack of training. While some physicians are naturally good teachers, most need to be taught the skills, and residency programs could be doing a better job.

“People are reluctant to do a lot of teaching because they don’t feel they are going to be good at it,” Dr. Kulaga says. “There is the fear that if I teach and I don’t do it well, I’m going to get criticized.”

Once hospitalists conquer that fear, however, Dr. Kulaga says, they will find their careers reinvigorated.

“Obviously, we work very intense schedules and see very sick patients,” he notes. “Doing that day in, day out can be wearing. It’s nice to have an outlet so you don’t burn out, so you can stay fresh and add variety to what you do day-today. Teaching keeps hospital medicine from being too much of a grind.”

Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.