The big question for academic hospital medicine is: with the cadre of hospitalists ballooning to 20,200 in 2007 and projected by the Society of Hospital Medicine (SHM) to hit 30,000 by 2010, are there enough teachers to go around?
Good teachers from all walks of life love what they do, enjoy imparting knowledge to apprentices, and usually have fine senses of humor, self-awareness, and security in the body of knowledge they are passing to the next generation. The best are role models and mentors. Hospitalist teachers are no different, and because they spend their professional lives delivering acute care in hospitals, they have advantages as teachers over their offi ce-based colleagues who complete hospital rounds quickly, then depart. The big question for academic hospital medicine is: with the cadre of hospitalists ballooning to 20,200 in 2007 and projected by the Society of Hospital Medicine (SHM) to hit 30,000 by 2010, are there enough teachers to go around? Additionally, can teaching hospitals provide enough slots for academic hospitalists to train new hospitalists? And are medical schools updating their curricula to include units on hospital medicine?
Supply and demand Overall, the supply of hospitalists who want to teach is meeting the demand. Faculty appointments for hospitalists who want them are generally available because of a faculty-friendly employment model that has evolved. The scheme incorporates adequate teaching time by keeping academic hospitalists’ average number of encounters and hours worked relatively low. Total compensation is less when compared to non-academic hospitalists off set by smaller patient loads. (See Hospital Medicine Group Numbers are Teach-Friendly)
The burgeoning number of medical students and residents who want to be hospitalists has prompted HMG leaders to create programs that allow academic faculty to have the right mix of clinical, teaching, and administrative responsibilities. By striking the right balance, seasoned hospitalist leaders have attracted academic faculty who enjoy and are good at teaching inpatient medicine.
Tapping into the supply of extra special teachers, though, can be diffi cult. “It’s a national problem fi nding highly qualifi ed and skilled hospitalists with great clinical judgment and stellar teaching skills. It’s increasingly challenging, because all the great teaching hospitals are competing for this pool of top talent,” says Scott Flanders, MD, FACP, President-Elect of the Society of Hospital Medicine, Clinical Associate Professor of Internal Medicine, and Director of the Hospital Medicine Program at the University of Michigan Medical Center (UMMC). He looks for teaching hospitalists who honed their skills through rigorous residency programs and were also chief residents. He has learned to avoid great clinicians who talk a good game but are not genuinely interested in teaching.
For Jasen Gundersen, MD, MBA, Division Chief, Hospital Medicine,UMass Memorial Medical Center, there is no lack of eager teachers in his 49 FTE hospital medicine group. “There are more people who want to teach than we have slots for,” says Gundersen. Drawn to the UMass program are physicians committed to hospital medicine with strong clinical backgrounds who want to teach. The compensation package and work load, a solid base salary, and fewer work hours per year than most programs (1,900 hours) have reduced turnover and created an environment conducive to teaching. “We don’t push our academic faculty to work 2,300 hours, because we want them to avoid burnout. Flanders adds to that sentiment: “Hospitalists can have a lot of down time, but if you build teaching into the schedule, the day gets more hectic but more satisfying.”
At UMass, hospitalist salaries climb for the fi rst six years and, if physicians stay longer, the number of hours they work is reduced each year. “Th is is attractive for hospitalists who want to teach,” adds Gundersen. His problem is a shortage of academic faculty slots because a number of senior community-based attending physicians have not turned their inpatients over to the HMG.
What both excites and challenges academic hospitalists is how they, as generalists with the run of the hospital, interact with subspecialty departments. Although hospital medicine is still dominated by internists (82.3%), the 10.5% of hospitalists who are certifi ed in something other than internal medicine, family medicine, or pediatrics add another dimension to the academic hospitalist ranks. Gregory Chang, MD, board-certifi ed neurologist, and Professor of Neurology, at the University of California at Irvine, is in a 16-person, multidisciplinary hospitalist group. He says there are enough neurohospitalists at large academic medical centers to mentor students and neurology residents and that the rewards of being a teaching neurohospitalist are many. “Because we have nine subspecialties in our HMG and we interact with other physicians regularly, we’ve broken down walls and leveled silos that exist in the department system. Now we’re in constant communication with other physicians, leading to a more comfortable level of care,” says Chang.
Chang says spending 100% of his time on inpatient care rather than splitting his time between the medical school, offi ce, and the hospital, as he did before becoming a hospitalist, has made him a better teacher. “The med students round with us for their one month neurology rotation, and we show them how to practice better, cost-eff ective medicine. I’m always teaching, and the students are seeing patients with acute neurological disease. They learn by doing, by using evidence-based medicine such as our stroke protocol as a guideline, and by intense exposure to inpatients,” he adds.
The University of Michigan Medical Center’s large hospitalist medical group under Dr. Flanders has two teaching services; a nonresident service for medical students staff ed by 26 hospitalist faculty and a resident service, with 10 faculty. Although academic hospitalists perform the traditional roles of attending physicians, their availability in the hospital allows for residents to work at the bed side with ‘the boss’ and to have more hands on time to learn from their teachers. As for productivity and compensation, Flanders explains that the University of Michigan HMG generates RVUs that are comparable to any group, partly because it bills for work done by residents. Faculty and students also contribute to the hospital’s process improvement through projects that address patient safety and resource utilization issues.
Academic HMGs have become stalwarts of hospital medicine. Armed with core competencies on which to build curricula— and piloted by leaders who have developed practice models that suit teaching hospitalists, students, patients, and administrators—they have established a new model of training doctors that emphasizes acute clinical care and better resource utilization. The discipline has come a long way in a few short years—teachers are evolving into coaches. Jeff rey Wiese, MD, associate professor of medicine, Tulane University Health Sciences Center, explained at a Society of Hospital Medicine workshop that for academic hospitalists, coaching transcends teaching a skill to demonstrating that skill in context, and then helping the student to anticipate and solve problems. Hospitalist teachers immerse medical students and residents in the acute care environment. Th ey talk them through the process of navigating inpatient resources, train them in emergency medicine, deliver health economics 101 on the fl y, and serve as models in palliative and endof- life care. It’s an exciting time to be a teaching hospitalist.
Recent Research on Academic Hospitalists
Research indicates that academic hospitalists are eff ective teachers—even more so than their subspecialist peers. Kripalani, et al. (Gen Intern Med 2004 Jan:19(1):8-15) compiled ratings by 423 medical students and residents of their 63 attendings; hospitalists ranked highest, with internists and subspecialists second and third, respectively. Hospitalists’ enthusiasm for teaching and emphasis on evidence-based medicine impressed students, as did teachers who graduated in the 1990’s versus physicians who graduated medical school earlier. A 2001 study by Karen Hauer et al. (Academic Medicine 2001Apr; 76(4):324-330) of pediatrics, family medicine, and internal medicine medical students documented the advantages of hospitalist teachers: expertise in inpatient medicine, teaching throughput, and availability throughout the day to teach when issues with patients arose. Students said their hospitalist teachers were role models in delivering high-quality-effi cient care.
Hospitalist Clinician Educators (HCEs) got high marks from their residents in teaching hospital management and clinical skills. The HCE’s taught how to reduce consumption of hospital resources and ALOS by 20%, and reduce cost per case in eight of 11 major diagnoses. Kulaga, et al. (Gen Intern Med 2004 April; 19(4):293-301) reported that 75% of residents preferred HCEs over other teachers. Hospitalist teachers in a study by Gaskey and Kees-Folts (J Hosp Med Jan 2007;2(1):17-22) were preferred over non-hospitalists by third-year medical students. Their teaching was described as “more eff ective and satisfying,” and rounds “went better with hospitalists.”
Core Competencies With their usual gusto, SHM’s academic hospitalists tackled the curriculum issue head on in 2006 by releasing a set of “Core Competencies in Hospital Medicine: A Framework for Curriculum Development.” Divided into three sections— Clinical Conditions, Procedures, and Healthcare Systems—this resource delineates the core knowledge, skills, and attitudes necessary for effective inpatient practice. The Core Competencies has become a foundation for instructors to build curricula and to standardize and improve training practices.