Like teenagers exploring their options and testing their wings, many hospitalists wrestle with the question “What do I really want to do when I grow up?”
That may be particularly true for hospitalists who are contemplating a career in academic medicine, where it may not be easy to arrive at the right mix of clinical practice, teaching and research.
Hospital medicine is still a relatively new field, and many academic medical centers struggle with how to position hospitalists within their academic network. In some cases, hospital medicine is a free-standing division, but more often it's under the umbrella of general internal medicine. And the newness of the field means that there aren't a lot of seasoned mentors to guide the newcomers.
Image is also an issue. At most institutions, hospitalists initially earned their stripes by filling a staffing need as residents' hours were cut and community doctors sought to lessen the demands of caring for hospitalized patients. Being a hard-working clinician, though, doesn't necessarily propel a physician up the academic ladder toward the resources and power that titles often bring. Pulling in grants and publishing in journals does, but much of the research and academic work done by hospitalists is in quality improvement, which may not match the traditional notion of scholarly pursuits, some experts say.
“In many institutions, the main impetus for developing a hospitalist program was because the housestaff couldn't see all the patients. In other places, the programs started because the other academic physicians didn't want to supervise residents on the ward,” said Robert Centor, FACP, professor of general internal medicine at the University of Alabama at Birmingham and associate dean of the Huntsville Regional Medical Campus. But the desire to keep an institution running smoothly is different from the goal of being a first-rate academic center.
“How hospitalists are viewed within academics is changing and improving. But how not to be viewed as transient workhorses is a problem that many programs still struggle with,” said Bradley Sharpe, FACP, an associate division chief in the hospital medicine division at the University of California, San Francisco.
At a crossroads
Leaders in the field are working to better define the role of hospitalists in academia and pave a clearer path for doctors who want a career combining patient care with teaching or research or both.
“Academic hospital medicine is at a crossroads,” concluded a consensus committee that included representatives of the Association of Chiefs of General Internal Medicine (ACGIM), the Society of Hospital Medicine and the Society of General Internal Medicine (SGIM). In 2007, the committee began looking at the challenges facing academic hospitalists and developing strategies to help them navigate their careers.
One result is a “Quality Portfolio” template developed by the ACGIM/SGIM Joint Academic Hospitalist Task Force (available on SGIM's Web site) –programs/quality-portfolio , which academic hospitalists can use to document the specific ways they contribute to improving the quality of patient care and patient safety. The idea is that while doctors are good at updating their resumes with accomplishments such as publishing papers and winning teaching awards, they often fail to articulate their quality improvement efforts. Having a quality portfolio could help doctors as they seek promotions and raises.
“Mainly what we're doing as hospitalists is quality improvement work,” said Jeffrey Schnipper, ACP Member, director of clinical research for the hospitalist service at Brigham and Women's Hospital in Boston. “But that is a path less traveled to promotion.”
Some institutions have developed their own assessment tools for hospitalists that consider the multiple aspects of working in an academic setting. Jonathan Stallkamp, MD, who directs the hospitalist program at Lankenau Hospital just outside Philadelphia, assigns bonuses by using a tool that gives equal weight to clinical and academic-related duties.
“You want to make sure your hospitalists are involved in all aspects of the hospital,” said Dr. Stallkamp. He said his staff seems to like the tool because it objectively measures the many things they do—from meeting core measures to mentoring a resident.
The opportunities for hospitalists are surely bound to increase in academic-based institutions as the dual push for quality and cost-effectiveness intensifies. Here are some points that physicians looking at potential jobs should consider.
Do you really want to be in academic medicine?
Hospitalists often will say they love their work because it's patient-centered and in the moment, but a position that includes teaching duties and research activities demands a different rhythm and changing focus.
“If you're outside of an academic medical center, when your day is over you turn off your pager and go home,” Dr. Sharpe said. “When you're an academic hospitalist, when you finish at the end of the day or go off service you still have work to do. Hopefully it is work you find rewarding and stimulating. But realize that even with the additional responsibilities and expectations, the salary will probably be substantially less for an academic hospitalist than for a non-academic.”
According to Karen DeSalvo, FACP, chief of general internal medicine and geriatrics at Tulane University in New Orleans, “research requires a set of skills and personality traits that sometimes are in conflict with what clinicians do.” Unlike the on-the-spot decision-making required in clinical work, research requires reflection and a willingness to recheck data again and again. Finding funding for the type of quality-focused research projects hospitalists tend to do can be a challenge, and not every doctor is cut out for the diligence needed to land research dollars.
But there are plenty of upsides to academia, too. Working on individual or collaborative research projects can be highly satisfying, and teaching medical students and residents helps clinicians stay up-to-date on the latest thinking about treatment modalities. Many doctors simply like the intellectual atmosphere that can come with an academic-affiliated center.
“There are huge resources, access to specialists, that aren't available in every center, and that's tremendously satisfying when it comes to comes to clinical care,” said David Meltzer, FACP, chief of the section of hospital medicine at the University of Chicago. But he said hospitalists wanting to get into research need to honestly ask themselves, “Am I prepared?”
Knowing how to do research takes training, which can be gained through a fellowship in hospital medicine or by working on projects as part of a larger team. Professional meetings and mini-courses can also be useful. SHM, SGIM and ACGIM recently sponsored “Academic Hospitalist Academy,” a four-day boot camp of sorts that focused on issues related to research, teaching and navigating the academic culture.
Does having a division of hospital medicine matter?
While it's easy to debate the virtues of being in a separate division versus being part of general internal medicine, what probably matters more is whether hospitalists are respected within the institution and whether good mentoring is available.
“If you're under a division of general medicine, the advantage is they may already have a research shop you can take advantage of, they have mentors, they have statisticians,” Dr. Schnipper said. “The disadvantage is they may not always understand the kind of research you want to do, so you may need to get that advice and support from elsewhere. Mentorship is probably the most important thing. There are so many challenges to getting a successful research career up and running that it is crucial that someone is available who knows how to get funding, how to budget your time, how to say yes or no to projects.”
Dr. Meltzer said newcomers to an institution, whether in a division of hospital medicine or general internal medicine, need to keep their eyes open for possible mentors outside their department. For someone interested in glycemic control, for instance, “a hospitalist mentor might be great, but so could an endocrinologist,” he said.
What does the job entail?
There are all sorts of ways to combine the job of clinician-educator-researcher. It can entail mostly patient work and a little bit of clinical teaching, or a lot of teaching and not as much patient care. Research expectations are another variable in the job makeup. Hospitalists may get a set number of weeks a year set aside for research, or it may be something they fit in around the edges.
“There are people who come in as clinicians and want to migrate into education,” Dr. Centor said. “For those of us who want to teach, the teaching keeps us fresh.”
But being a good teacher doesn't usually come naturally, and hospitalists are often thrust into teaching duties right out of residency with little or no training. At the least, finding a good mentor to learn some of the tricks of the trade will help, and hospitalists who find ways to shine in their teaching roles do get noticed.
In Dr. DeSalvo's experience at Tulane, she said, hospitalists usually learn to thrive, and advance, in the academic environment.
“Hospitalists tend to be a very motivated, self-driven group,” she said. “I'm struck by how hungry they are.”