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More community hospitals performing cutting-edge research

A solid program can be an effective hospitalist recruitment tool

From the May ACP Hospitalist, copyright © 2007 by the American College of Physicians.

By Stacey Butterfield

As the role of hospitalists evolves at medical facilities around the country, some community hospital physicians are adding a new line to their job descriptions—medical researcher. Although research has historically been the province of academic medical centers and government labs, more community hospitals are now getting in the game, reaping benefits for hospitals, patients and physicians.

"Some top clinicians happened to be here at the community hospital. To stay cutting-edge and on top of our specialties and to attract residents and patients, we decided we'd like to do research," said Mansur E. Shomali, ACP Member and director of research at Union Memorial Hospital in Baltimore.

Research can bring prestige to a hospital, innovative treatments for patients and interesting challenges and publication opportunities for physicians who may prefer community-based clinical practice to work at an academic medical center.

In certain ways, community hospitals may be better suited to research than academic medical centers, Dr. Shomali noted. "The idea is that we could do it better because we're where all the patients are, and at the university, it's not a true reflection of the practice of medicine in the community."

Many patients at university hospitals have multiple medical problems that can complicate results, or have to be recruited with the promise of payment to participate in a study. Community hospitals, on the other hand, have a constant supply of patients who usually represent a good sampling of the general population.

The challenge lies in developing a research program that best utilizes the specific assets of your hospital. Dr. Shomali and other experienced community hospital researchers offer some advice to help new hospitalist researchers get off on the right foot.

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Start simple

Although almost any kind of research can be conducted at a community hospital, one of the simplest methods for a new program is to start with data that are already being collected.

"A lot of community hospitals have to have some sort of a research-like mechanism for performance improvement," said Dr. Shomali. A hospital's performance data can be used to develop and measure the effectiveness of new interventions or procedures—such as a hospitalist program itself.

Bradley T. Rosen, MD, medical director of the hospitalist program at Cedars-Sinai Medical Center in Los Angeles, used his hospital's data collection systems to study the performance of hospitalists. After collecting data on length of stay, readmission rates, resource utilization and other factors, he has hard numbers to demonstrate the value of the hospitalist program to administrators.

"The argument is that the money they put up front is going to more than pay for itself with greater efficiencies. By averting unnecessary admissions through appropriate screening of patients in the ER, for example, we're saving potential denials of payment, opening up beds and decreasing complications," Dr. Rosen said.

Pharmaceutical trials are another popular avenue for hospitalists starting research programs. Drug companies are always looking for sites to test new medications, or new indications for pre-approved medications. In many cases, hospitalists' regular pharmaceutical sales representatives can put them in touch with the contacts to set up a study, said Danny Liaw, ACP Member, a hospitalist at Lehigh Valley Hospital in Allentown, Pa.

The major advantage of conducting a pharmaceutical study is that it comes ready-made and fully funded. "The physician doesn't have to come up with the idea, doesn't have to make the research protocol, just has to find the patients and make sure that the patients voluntarily sign up for the project," Dr. Shomali said.

Studies funded by pharmaceutical companies do entail a risk of conflict of interest, however. "I know that I can improve my budget by recruiting a patient to the study. Am I going to be looking at that patient as a physician or as the investigator in the study?" asked Dr. Shomali.

An awareness of the potential for conflict can help a physician guard against it. "The physician-investigator has to carry two hats and the physician hat has to be worn first and foremost at all times," Dr. Shomali said. When recruiting patients into a study, he always assures them that they will receive the best care possible whether or not they enroll.

A hospital's research ethics committee or institutional review board (IRB) can also ensure that any proposed study has safeguards in place to protect patients and physicians from potential conflict of interest. Physicians at hospitals without an IRB can submit studies to a freestanding board for review.

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Gather support

In addition to IRB review, research projects have to go through hospital administration, not always an easy task, said experts. Community hospital administrators may not initially see research as part of their institution's mission.

"Couch your argument in terms of how it's beneficial to the hospital," advised Dr. Liaw. Research can attract prestige, patients, even physicians to a community hospital. James A. Welker, DO, director of the Franklin Square Clinical Research Center in Baltimore, noted that greater administrative support for research was one of the main reasons that he transferred from one hospital to another.

"The physician-investigator has to carry two hats and the physician hat has to be worn first and foremost at all times." —Mansur E. Shomali, ACP Member

Other departments of the hospital may need to sign on to a study. "Before a hospitalist agrees to do a pharmaceutical study, he must meet with the director of the laboratory and the director of the pharmacy. The lab and the pharmacy will always get paid for what they're asked to do, but what if they don't have sufficient staff?" said Dr. Shomali. A quick check-in before the study can avert major hassles later, he said.

Extra staff will probably be needed in the data collection portion of a study. Hiring a research coordinator or research nurse to deal with paperwork is necessary and often cost-effective, said Dr. Shomali. "If you have three or four projects going at any given time, it can usually pay the salary of the research coordinator," he said.

For researchers on a limited budget, residents can be a source of assistance. Residents are often eligible for small grants from their own institutions or external academic organizations that can be used to fund research if you’re willing to take a resident under your wing, said Dr. Liaw.

Hospitalists also shouldn't hesitate to look around for help with the statistical side of research, either within the hospital or outside. Maybe a statistics professor at a local community college would be willing to collaborate, Dr. Liaw said.

While gathering collaborators, it's important, although sometimes difficult, to get other physicians at the hospital on board with the idea of research, said Dr. Welker.

For example, a prominent physician at his hospital supported proposed research in meetings, but repeatedly declined to have his patients participate in studies. Community hospital physicians are often uncomfortable with providing anything other than the recommended standardized care, and those who pay their own liability insurance may be worried about the risks posed by studies, he said.

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Choose patients

The best way around the problem can be through the patient. "Usually what happened was that the physician was hesitant and the patient wanted to participate so the physician said OK. Then the patient did fine in the trials, and they realized that we're not doing things that are particularly dangerous," said Dr. Welker.

Recruiting patients for research is not usually a problem, as long as you pick a study topic that affects a reasonable number of your hospital patients, Dr. Shomali said. For example, you don't want to sign a contract to test a drug for a rare hematologic condition if you're only going to see one patient with that problem in a year.

To avoid that issue, cancer and cardiovascular diseases are good areas for research, according to Margot C. LaPointe, PhD, director of research at Henry Ford Health System in Detroit. "Community hospitals tend to get a lot of patients in through the emergency room that are either having heart attacks or strokes," she said.

The most important criteria for a research topic, however, is that it is something you are interested in, said Dr. Shomali. "It's nice to pick just one or two areas of medicine that will be interesting as well as good for one's patients because hospital medicine is so broad. You'll be better at it. You'll know more about it than the average hospitalist."

Transitioning from average hospitalist to expert hospitalist-researcher is a time-consuming, challenging and not necessarily profitable process, the experts cautioned. But for Dr. Shomali, the effort is worthwhile.

"If we break even and enjoy what we do and contribute to medical science, that's the driving force," he said.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated