An academic time crunch

Academic hospital medicine was a different job back in the day.

“It was predominantly one of traditional teaching, with house staff, medical students, and the like. You could even go back to your office occasionally and work for a little bit,” said Marisha Burden, MD, MBA, FACP, who entered the profession about 17 years ago.

Richard Elias, MBBS, FACP, remembers those times, too. “Certainly long gone, I would say, are the days where people would go into academic practice because it's quiet or it's more relaxed,” he said.

The pandemic accelerated an evolution in academic hospitalists' workload that was already in process, according to those who've been in the field awhile.

“I think it's a nationwide or global phenomenon that hospitalists are being asked to do more and more clinical care,” said Stephanie Parks Taylor, MD, MSc. “The reward for doing work well is the opportunity to do more work.”

But how does a person, or a program, get all that work, which still includes education and research, done? It's a question that hospitalist leaders have recently been struggling with, and sharing their experiences in the hopes of developing some effective solutions.

Scope of the job

Hospitalists have always faced competing priorities, noted Dr. Taylor, who is a professor and division chief of hospital medicine at Michigan Medicine in Ann Arbor.

“Something we've been battling from the inception of the specialty is the balance. It is a specialty that literally was born out of the need to provide clinical care. But it's also a specialty that has researchers and educators and folks that want other parts of the academic portfolio,” she said.

But lately one component of the job has swallowed more of academic hospitalists' time. “The patient care responsibilities' rate of growth is just so much faster than the educational rate of growth,” said Luci Leykum, MD, FACP, affiliate professor of medicine at Dell Medical School in Austin, Texas. “In some places, it just gets busier and busier, so there's more people to see, and we also need to move them through the system faster.”

That's also the part of the job that gets top priority, added Dr. Burden, a professor of medicine and division head of hospital medicine at the University of Colorado School of Medicine in Aurora.

“There can be a tension between clinical duties and educational duties. There's a point at which the clinical work is too much and you feel like you have to prioritize one or the other, and if you're dealing with sick patients, you're going to choose taking care of the sick patients first and then education may fall by the wayside for that day,” she said.

To see how hospitalists are handling this problem, Dr. Burden and colleagues recently surveyed a group of academic hospital medicine leaders about the impact of clinical growth on their educational mission. “We wanted to understand: Are we unique? Are others facing similar problems? … Has anybody else figured this out?” she said.

According to results published by Annals of Internal Medicine on Nov. 14, 2023, the broad answers to her questions were no, yes, and not quite. “There's a lot of strategies that hospitalist leaders and their groups are using, and I think they're innovative. Does it make absolutely everyone happy? Probably not,” said Dr. Burden.

Along similar lines, a group of physicians who do research recently asked 10 hospital medicine leaders how those who share that career interest fit it into hospital practice in their programs. The results of their interviews were published by the Journal of General Internal Medicine, also on Nov. 14.

That study didn't find any really good solutions, either. “The prevailing paradigm for accessing protected time is one which encourages and rewards pursuing research work during non-work hours,” the authors concluded.

“Leaders in hospital medicine know this and they acknowledge this,” said Dr. Elias, lead author of the study and assistant professor of hospital medicine at Mayo Clinic in Rochester, Minn. “Our colleagues are busy and there's just less of that diastole time, less of that time off to pursue scholarship.”

Balancing the mix

The problem is not just too much work, but a mismatch between the work at hand and academic hospitalists' preferred activities, the experts noted.

Dr. Burden's research found that it was common for demand for teaching roles to outstrip supply in the surveyed academic hospital medicine programs. “The position of being an attending physician on a traditional teaching team consisting of residents and medical students was noted to be highly desired by many hospitalists,” the study results said.

Hospital medicine programs are trying a variety of solutions to cover their clinical demands while also trying to meet physicians' desires to pursue other career interests.

One solution is to add teaching to less traditional roles. “There are efforts to create more educational opportunities in these patient care activities—have fourth-year medical students do a subinternship, or have a resident elective in hospital medicine or even nursing or pharmacy students, other learners” on direct care services, Dr. Leykum suggested.

Another strategy has been to create a waiting list to teach. “Increasingly, what we saw in the study is, as faculty are hired, it may be some time before they get traditional teaching time,” said Dr. Burden.

An alternative to the seniority system is to dole out teaching roles based on physicians' assessed skills in that domain, according to Samantha Wang, MD, a clinical assistant professor of hospital medicine at Stanford University in California.

“When we think about education, we need to think about it as a skill and less of something that anybody can just do off the bat,” she said. “One of the things I think is important is holding our educators to a set standard and making sure that the educators who do get time on teaching services are meeting the expectations of being a great teacher.”

The downside of merit-based allocation of teaching time is limited opportunity for improvement, said Dr. Leykum. “People who have good skills, you reinforce them, but people who may not have as good skills, a lot of them are just less experienced, and then they don't have the opportunity to gain more experience.”

Getting, and staying, better with practice came up in a recent debate between Dr. Wang and colleagues published Oct. 9, 2023, by the Journal of Hospital Medicine. The point-counterpoint article asked, “Should teaching hospitalists be required to provide direct care?”

It's increasingly rare for them not to be, noted Dr. Wang, who coauthored the “no” position in the article. “It's definitely in the minority to be in a position where you are purely on a teaching service,” she said. “The concern is, in order to address the increasing needs in volume and the staffing shortage, are we pulling people away from their passions and dedication and putting them on nonteaching services, where they don't get to hone their educator skills?”

The same issues arise for hospitalists interested in research, Dr. Elias said. “The data suggests that academic hospitalists want to pursue research, they want to pursue academic promotion, and so there's going to continue to be this tension between the increasing clinical demands on hospitalists and the desire to produce scholarship.”

Making clinical enjoyable

As Dr. Elias's mention of promotion indicates, it's not exclusively intellectual passion that makes academic physicians desire nonclinical assignments.

“Faculty feel a tension in that the clinical responsibilities are more valuable to the financial bottom line, and the academic responsibilities tend to get more prestige,” Dr. Taylor said. “The more clinically focused faculty who are doing phenomenal work and often have regional or national presences from their clinical expertise—it's been harder to get them up the traditional promotion pathway.”

A solution is for academic medicine programs to respond to current trends by ensuring that promotion pathways acknowledge some of the newer nontraditional teaching roles, like training advanced practice clinicians on a direct care service, Dr. Burden noted. “There are very traditional views right now of what an academic hospitalist is, which is you're an educator and you're on that traditional teaching service, when it's actually so much more.”

Dr. Taylor agreed. “One of the things we've been working on is an academic pathway for master clinicians,” she said. “Rather than, ‘Oh, you're just the hospitalist providing world-class direct care,’ we're building a special academic role that comes with clinical mentorship and scholarly work related to clinical expertise, like writing review articles or clinical guidelines.”

Along with being respected, such roles also need to be sustainable for those who do them, the experts noted.

“A fundamental question is how do we make the clinical work more attractive and not feel like such a boulder being pushed uphill?” said Dr. Leykum. “Some of that is volume and some of that is how do we make the work inherently easier? It's not even burnout but just feeling like the system is moving in ways that aren't helping me to work with the people that are coming into the hospital.”

Those systemic issues contribute to workload, which is “the real underlying factor” in the academic discontent, according to Dr. Burden. “Right now, the way we fix the overwork problem is you just stay late, right? You may barely sleep when you're on service trying to get it all done. It's a workaround. Not a healthy one.”

She studies hospitalist workload and thinks additional data on this topic will prove the need to rethink both the load and the design of it. “This comes down to a financial conversation, but I think we often look at those financial conversations in a very fixed and short-term kind of way,” Dr. Burden said. “We forget to look at how many patients were harmed? How was throughput impacted? How many faculty have left the job? Did we serve our educational mission?”

Program leaders also need to create a sense of fairness among hospitalists with these differing responsibilities, Dr. Burden added. “Groups compare different aspects of their work to each other. How do you build a cohesive team culture that's transparent, fair, and has a readily apparent framework?”

Academic jobs will also be compared to those in community hospitals, particularly if they are increasingly comprised of direct care. “How do you differentiate that from the community jobs, which pay a lot more?” Dr. Burden asked. “It becomes a tricky conversation when the productivity measures are not all that different from community to academic and the salaries are dramatically different.”

Future predictions

Given the appeal of education and research work, the experts predicted that most academic hospitalists will find a way to continue to wear these multiple hats and make it sustainable.

“As the specialty matures, I think that we're going to see more cohesiveness among faculty who provide primarily clinical care, and those with primary education, research, other academic interests. There will be more opportunities to blur these lines and create a culture where everyone is on the same team advancing the tripartite mission,” said Dr. Taylor.

“People coming into academic medicine now have to be highly motivated to juggle what can be a very challenging set of time constraints,” noted Dr. Elias.

To deal with those, the experts recommended looking for ways to multitask. “In hospital medicine, there can be a pretty big overlap between research, education, and clinical care,” said Dr. Taylor. “Double dip and find research and education opportunities in the clinical care that you are providing or in the leadership roles that you have, solving health outcome or quality-of-care questions or operational efficiency questions. … They don't have to be three different fires that you're stoking separately.”

Also, don't forget that you're not alone in these challenges. “Take advantage of your colleagues and your professional societies. Every place is working through these issues,” said Dr. Leykum. “If nothing else, you realize, hey, some of these issues are universal, so it's not just that we're doing something horribly wrong here that we're having these challenges.”

Finally, take heart that good times in academic hospital medicine are not just in the past, from someone who was there. “It's going to look different than it did 15 years ago, but I don't think that means that it's any less of an ideal job,” said Dr. Burden. “I love my work.”