Graduate Medical Education A Novel Housestaff Educational Model for Quaternary-Care Patients at an Academic Health Center Jennifer C. Lai, MD, MBA, Alex Montero, MD, MPH, Benjamin Lebwohl, MD, and Robert S. Brown, Jr., MD, MPH Abstract Purpose Work hour restrictions, external pressure to reduce hospitalization costs, and rising inpatient acuity have prompted a variety of changes in the ward-based educational models traditionally employed in residency training. The impact of these changes remains largely unstudied. Method The authors collected data retrospectively on hospital patients with advanced liver disease before (July 1, 2003, to May 31, 2004) and after (July 1, 2004, to May 31, 2005) implementation of a novel specialized housestaff service (SHS) model for those patients, supervised by a multidisciplinary hepatology team led by an attending hepatologist. The authors also assessed the satisfaction of the 118 internal medicine residents who had rotated through both the SHS model and a traditional housestaff service (THS) in cardiology. Results In univariate analysis, there was a trend toward a reduction in mean length of stay (LOS) after implementation of the liver service that did not meet statistical significance (P = .1). After adjustment for patient acuity and Model-for-End- Stage-Liver-Disease score, implementation of the liver service was associated with a statistically significant reduction in LOS (P = .05). In contrast, during the study period, there was an increase in LOS on a comparable, nonspecialized medicine housestaff ward even after adjustment for patient acuity (P  .01). With respect to housestaff satisfaction, 90% of housestaff reported being satisfied overall with their experience caring for patients under the SHS model, with a mean score of 4.1 on a 5-point scale. Conclusion The implementation of the SHS model of patient care is associated with a decreased LOS and increased trainee satisfaction when compared with the THS model of patient care. Acad Med. 2009; 84:206–211. Residency training in internal medicine remains a largely inpatient, ward-based experience, where the trainee is exposed to patients with a variety of diseases— ranging from acute presentations, such as pneumonia and pulmonary embolism, to exacerbations of chronic illnesses including liver disease and chronic obstructive pulmonary disease. 1 Traditionally at our institution, patients are admitted to a medicine service and managed by medicine housestaff under the direct guidance of either the ward attending or an admitting private attending, regardless of the acuity or complexity of the patient’s condition, often with consultative input from specialist physicians. Recently, however, external factors have had a significant impact on the educational environment within residency training, necessitating a variety of adjustments to the traditional service model. 2– 4 Economic pressure to reduce length of stay (LOS) has shifted care to the outpatient setting, resulting in trainees’ caring for inpatients with conditions of higher acuity. Additionally, in many academic health centers, patients receiving quaternary- care interventions, including organ transplantation, have become increasingly common and represent a unique subgroup of patients with high-acuity, complex conditions who require management input from a subspecialist outside of the traditional service model. Lastly, implementation of resident work hour restrictions and increased economic pressures to see patients largely in the outpatient setting for attending physicians have potentially decreased opportunities for formalized teaching between attending physicians and residents, thus lessening residents’ satisfaction with the training experience. 5–7 As residency programs adjust to these competing influences, the traditional service model of patient care may no longer represent the optimal structure for delivering high-quality care while still achieving trainee educational goals. In response to the changing training environment, we implemented the liver service—a novel ward-based educational model for internal medicine residency training— dedicated to patients with end- stage liver disease. We hypothesized that for these quaternary-care patients, a specialized housestaff team structure directly supervised by a subspecialist would improve the clinical care of a group of patients with similarly high- acuity, complex conditions while Dr. Lai is a first-year gastroenterology fellow, University of California–San Francisco, San Francisco, California. At the time of this study, she was an internal medicine resident, New York Presbyterian Hospital–Columbia Presbyterian Medical Center, New York, New York. Dr. Montero is assistant professor of internal medicine, Columbia University College of Physicians and Surgeons, New York, New York, and associate program director of the internal medicine residency program, New York Presbyterian Hospital–Columbia Presbyterian Medical Center, New York, New York. Dr. Lebwohl is a second-year gastroenterology fellow, New York Presbyterian Hospital–Columbia Presbyterian Medical Center, New York, New York. Dr. Brown is chief, Division of Abdominal Organ Transplantation, and Frank Cardile Associate Professor of Medicine and Surgery, Columbia University College of Physicians and Surgeons, New York, New York. Correspondence should be addressed to Dr. Brown, Center for Liver Disease and Transplantation, New York Presbyterian Hospital–Columbia Presbyterian Medical Center, 622 West 168th Street, PH 14 Center, New York, NY 10032-3784; telephone: (212) 305-0662; fax: (212) 305-4343; e-mail: (rb464@columbia.edu). Academic Medicine, Vol. 84, No. 2 / February 2009 206