Is It Time to Be More Explicit About the Purpose of a Hospital Admission?

PURPOSE: Patient care suffers when teaching teams fail to achieve a shared understanding of problems to be addressed during a hospital admission. In academic contexts where attending physicians take turns supervising, practice variability may contribute to undermining this shared understanding. Exploring variability around what constitutes the purpose of admission to hospital was the focus of this study.

METHOD: Constructivist grounded theory was used to inform data collection and analysis of this two-phase study, conducted at London and Hamilton, Ontario, 2012. In phase 1 interviews with 24 attending physicians from two academic health centers were conducted. Phase 2 involved analyzing 18 audio-recorded admission case review discussions in relation to the emergent theory from phase 1. Participants for phase 2 were seven different attendings, seven medical students, and five junior residents.

RESULTS: Three dominant perspectives around the purpose of an admission were identified. The most focused perspective characterized the purpose as making patients ready for discharge. By contrast, the most comprehensive perspective characterized admission as an opportunity to identify ways to improve overall patient health status. The third perspective was in-between-treating acute issues while monitoring pertinent chronic conditions. All attendings expressed a sense of discharge pressure but responded with different strategies. Attendings rarely explicitly discussed their perspectives as part of case review.

CONCLUSIONS: These extremes of practice and lack of overt dialogue are concerning. Potential effects include mixed messages to trainees and missed opportunities for dialogue and debate around what can and should be achieved during a hospital admission.