A systematic review of evidence-based practices for clinical education and health care delivery in the clinical teaching unit

Background:The clinical teaching unit is a widespread clinical training model that requires reform to prepare physicians for practice in the 21st century. In this systematic review, we aimed to identify evidence-based practices in internal medicine clinical teaching units that contribute to improved clinical education and health care delivery.Methods:We searched several databases from 1993 until Apr. 5, 2021, to identify published studies in inpatient clinical teaching units that involved medical trainees and reported outcomes related to trainee education or health care delivery. We identified emergent themes using a narrative approach and determined confidence in review findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) methodology.Results:We included 107 studies of internal medicine clinical teaching units, of which 93 (87%) were conducted in North America. Surveys (n = 31, 29%), trials (n = 17, 16%) and narrative studies (n = 15, 14%) were the most prevalent study designs. Practices identified as contributing to improved clinical education or health care delivery included purposeful rounding (high confidence), bedside rounding (moderate confidence), resource stewardship interventions (high confidence), interprofessional rounds (moderate confidence), geographic wards (moderate confidence), allocating more trainee time to patient care or educational activities (moderate confidence), “drip” continuous models of admission (moderate confidence), limiting duty hours (moderate confidence) and limiting clinical workload (moderate confidence).Interpretation:In this review, we identified several evidence-based practices that may contribute to improved educational and health care outcomes in clinical teaching unit settings. These findings may offer guidance for policies, resource allocation and staffing of teaching hospitals.

Medical education in North America is largely based on an educational model that is now more than a century old.¹ To keep pace with changing social, economic and health system circumstances, substantial educational reform is necessary to prepare physicians for practice in the 21st century. Over the past decade, numerous national organizations, including the Association of Faculties of Medicine in Canada and the American Medical Association, have echoed this call to action.^1,2The clinical teaching unit (CTU) provides a joint model of undergraduate and postgraduate clinical education in which trainees contribute to direct patient care, with graded levels of responsibility reflective of their level of training.³ The CTU describes an approach to delivering learner education and patient care in parallel, and since its inception in Canada in 1962, this model of care has become almost ubiquitous across clinical specialties in many countries. Although the use of CTUs is a common approach to organizing an inpatient teaching service, the implementation of CTUs is highly variable with regard to elements such as the number of learners and patients, and regionalization to specific hospital wards. Moreover, a systematic evaluation of practices that maximize the CTU’s effectiveness has not been conducted, meaning evidence to inform CTU design is lacking.The purpose of this systematic review was to identify practices in internal medicine CTUs that contribute to improved clinical education for resident physicians and medical students, as well as to health care delivery.