How Does Care Team Structure Shape the Resident Experience?

Academic medical centers serve two important missions: providing excellent patient care and training the next generation of physicians. As hospitals seek to improve efficiency while meeting clinical and educational needs, they have developed new approaches to structure inpatient teaching services.

A new study from Yale researchers, published in the Journal of Evaluation in Clinical Practice, examined the educational impact of one newer model: a direct care hospitalist teaching service (DCHTS).

The DCHTS differs from a traditional teaching service in both the size of the team and its structure, explains Angela Kang-Giaimo, MD, MPH, assistant professor of medicine (general medicine) at Yale School of Medicine, and first author of the study. At Yale, both models operate as separate inpatient services, with senior residents rotating through each during their training.

On a traditional teaching service, an attending physician oversees a team that typically includes senior residents, interns, and medical students, with trainees taking on different levels of responsibility for patient care depending on their role and experience. A DCHTS, by contrast, pairs hospitalist attendings directly with senior residents to care for patients.

Those structural differences provide senior residents with distinct educational experiences, Kang-Giaimo explains.

“On a traditional teaching service, senior residents gain experience leading and educating a team of junior trainees,” she says. “On a DCHTS, they focus more directly on managing patients and work alongside an attending hospitalist in more of an ‘apprenticeship’ model.”

With fewer team members involved in each patient’s care, a DCHTS may offer a more streamlined approach to managing patients. Previous research has explored this and other ways that different team structures may affect resource use and patient care. Less understood, however, is how these models affect the residents working within them, says Kang-Giaimo.

To explore this question, the research team focused on one particularly important aspect of the resident experience: patient care ownership, or the extent to which residents feel responsible for and invested in the care of their patients.

“Patient care ownership encompasses autonomy, responsibility, quality of care, care delivery, and communication,” Kang-Giaimo says. “It matters to the physician, but it matters to the patient, too, because ultimately it shapes how we care for them.”

To compare residents’ experiences across the two models, the researchers surveyed senior residents who rotated on the DCHTS and traditional teaching service at Yale New Haven Hospital between April 2023 and June 2024. The survey used a previously validated 13-item instrument measuring patient care ownership.

The research team found that residents’ sense of patient care ownership was largely similar between the DCHTS and traditional teaching services.

For Kang-Giaimo, that similarity is meaningful. A different, potentially more streamlined model of care did not appear to come at the expense of an important aspect of residents’ professional development, she explains.

The findings suggest that academic medical centers may have flexibility to structure inpatient teams in different ways to meet institutional needs while preserving the resident educational experience.

Additionally, the study found that residents often pointed to the attending they worked with as more influential to their experience than the team structure. This finding opens the door to new questions about what shapes residents’ learning experiences, says Kang-Giaimo.

“If what matters most is who you learn with, then how do we ensure that attendings are the best teaching attendings they can be?” she adds. “And then the next question is, how does that impact patient outcomes?”

Ultimately, Kang-Giaimo hopes the findings encourage academic medical centers to continue testing new models of inpatient care.

“These innovative models can help institutions explore more efficient approaches to patient care while also ensuring that trainees are learning and developing a sense of ownership,” she says. “We should continue to innovate and try different things, and study how they impact patient care, the health system, and learners.”

The Department of Internal Medicine at Yale School of Medicine is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, educators, and staff in one of the world's top medical schools. To learn more, visit Internal Medicine.