Summit attendees spent considerable time developing and refining solutions to the challenges described above. Addressing the challenges resulted in a diverse group of proposed products that included educating key stakeholders, designing meetings, courses, or workshops, and gathering and disseminating data. There was considerable overlap among the solutions (Table ).
| Table 2Proposed Solutions to Overcome Challenges Facing AHM |
Outreach and Education to Stakeholders in Academic Medicine
The focus of the educational and outreach efforts suggested by the Consensus Group is to help leaders in academic medicine (not just AHM) and academic medical centers understand the challenges facing AHM. More importantly, efforts should reinforce the value of academic hospitalists to their hospital, department, and division. Efforts to engage these critical stakeholders to discuss and potentially address a number of the conference’s proposed solutions are needed. Leaders include deans of medical schools, chairs of departments of medicine, division chiefs, and hospital administrative leadership.
Outreach and educational activities suggested included publication of papers in key journals, with the goal of increasing the visibility of AHM in professional societies, as well as meetings and workshops focusing on teaching hospitalists and academic leaders’ methods to overcome challenges. Professional societies with a stake in AHM should better understand the challenges and position themselves to address these issues. The AHM task forces of SHM and SGIM can help give academic hospitalists a voice in having their needs addressed.
Publications
Manuscripts have been commissioned in the following areas: “Descriptions of Challenges and Proposed Solutions,” “Best Practices for Non-Resident Hospitalist Services,” and “Metrics for Success of Hospital Medicine Programs.”
Meetings / Workshops
Meetings and workshops, sponsored by professional societies with a vested interest in AHM, were thought an effective way to address the needs of hospitalists, particularly those pursuing careers as clinician educators. Such workshops would provide skills in teaching and early career survival (e.g. how to bill correctly), and developing an educator’s portfolio. Leadership training offerings, perhaps building on examples from SHM and the ACGIM, were also thought to be valuable resources, and venues which should be directed towards hospitalists, their chiefs, and relevant leaders.
Defining a Sustainable Job Description for Academic Hospitalists
The group strongly endorsed the need for transparent and readily available data aimed at developing sustainable academic hospitalist positions. For example, information required would include, how academic jobs are constructed (in terms of months on service/year, number of nights or weekends of coverage), and what successful programs and their hospitalists have found to be acceptable. Over the longer term, empiric comparisons based on key metrics are needed to not only help guide career development and retention, but also facilitate negotiations for programmatic support.
The group pointed out that, embedded in delineating an optimal academic hospitalist job description is the longstanding work of general medicine societies to support and foster the development of clinician-educators. In many ways the pressures of academic physicians to be ‘C-e’ (i.e. mostly clinician, less educator) vs. c-E (i.e. someone who focuses heavily on educational work) are similar for hospitalists and outpatient generalists. Academic general internal medicine divisions hired many general internists in the early 1990s to expand the reach of academic medical centers and increase the outpatient base.
6 Many university hospitals are now hiring hospitalists to provide the inpatient care for these patients, but residency work hour reductions have added a layer of complexity, creating the need for entirely new roles for academic generalists (such as surgical co-management of medically complex patients).
7,8 Past experiences in refining and reinforcing education as a key function (
http://sgim.org/clinicianteach.cfm ) would provide a template for future activities. Again, in the context of a rapidly growing number of non-teaching services, these descriptions have great importance.
Development of Quality-Improvement Portfolio Akin to an Educator’s Portfolio
Many hospitalists actively participate in administrative work related to quality improvement activities; we should develop this additional pathway for promotable academic activities (e.g. c-A, clinician-administrator), however such a pathway may not be recognized by all promotions committees. The group observed that many aspects of quality improvement are similar to those of education (e.g. development of a curriculum, leading a team, evaluation of a process, defining generalizability, and dissemination of locally proven interventions), and as such would be amenable to development of a ‘quality improvement portfolio’, which candidates could submit to promotions committees. Again, past work in developing the importance and value of the Educator’s Portfolio would facilitate the development of a QI portfolio, which would require endorsement from key stakeholders (e.g. APM, SGIM, SHM, and others).
9 Importantly, this work may also benefit many outpatient-based generalists who are increasingly focusing their careers on quality and safety improvement.
Developing Mentoring and Training Opportunities for Newly Hired and Junior Hospitalists
We reached a strong consensus on the need to develop a retreat-format training opportunity where junior academic hospitalists would be able to gain training in tasks critical to early career success. These were envisioned as an initial 2-3 day meeting followed by mentorship at a distance and continued collaboration within the ‘class’ of attendees. Topics would include key functions in AHM: how to become an effective attending physician and teacher, leadership, quality improvement, business of medicine, how to bill effectively, and how to maintain a curriculum vitae, among others. A number of professional societies have developed leadership or mentoring retreats, and at the time of this manuscript’s preparation there are both regional and national efforts underway to develop these products.
Developing Training and Mentorship Pathways for Hospitalist Researchers
There are few funded ‘hospitalist’ researchers at the mid-career phase, and a small but growing number of academic hospitalists entering the field with a focus on research. Enhancing a pipeline of researchers is a critical need for the field, as cementing AHM as an equal member of the academic medicine community will be predicated on the successful development of hospitalist investigators. To this end academic hospitalist groups should be encouraged to partner with other established research units (particularly general internal medicine) to create mentoring relationships and increase collaborative activities. Emergence of the clinical translational sciences consortium sites, with a focus on implementation and effectiveness research, may also provide local opportunities for hospitalists to partner in research important for early-career grant submission. Furthermore, building the ‘pipeline’ of academic hospitalist researchers will require a strong focus on identifying students and residents through outreach at individual sites, as well as presentations at national meetings (e.g. American College of Physicians).
Two other issues were also thought important. First, professional societies should work to encourage funders of primary-care focused general medicine training programs (NRSA, HRSA) to allow hospitalists to qualify for such critical research training. Secondly, continuing to advocate for increasing funding for implementation and effectiveness research, either via Agency for Healthcare Research and Quality or individual NIH agencies, will be key; emergence of a medical effectiveness institute would also be a potential boon.
Improving Relationships Between the Professional ‘Homes’ of Academic Generalists
Relationships between outpatient-based general medicine and hospital medicine were rocky as the field of AHM first took shape, and some residua of initial tensions persist a decade later. Persistence of these tensions are, in part, because hospitalists remain underdeveloped members of the academic community, perhaps giving some license to aver that hospitalists are merely transient faculty in a stage between residency and fellowship hired to improve throughput.
Overcoming this perception will require more engagement between academic generalists of all types, not less. The consensus group felt strongly that there need not be a single professional ‘home’ for academic hospitalists, and that generalists should be willing and even encouraged to self identify as hospital or clinic-focused, much as they might be geriatrics-focused, informatics-focused, or women’s-health focused. And in fact, in some academic centers, a few generalists have successfully integrated themselves into both clinic-based and hospitalist roles. In this way, the emergence and growth of AHM should be viewed as a boon to the practice of general medicine, not a challenge.
Resources
Much of what is proposed to enhance AHM will require resources. Academic hospitals have a vested interest in supporting AHM as a way to reduce turnover in a group which is increasingly critical for hospital operations, not to mention key leadership roles. Negotiating for these resources should emphasize that hospitals benefit directly from the revenue and margin that comes from incremental hospital admissions, collect most of the federal graduate medical education dollars, and benefit from improved care processes that are a result of hospitalist quality improvement efforts.
Deans and departments, a key audience for the conference findings, also have a clear stake in fostering a less transient, more professionally satisfied and academically successful work force, particularly when hospitalists are increasingly the key educators of medical residents. Moreover, schools have a vested interest in the academic accomplishments and national reputation of their hospitalists. The financial arrangements will be unique to each setting and institution, and it is clear that the sources to be tapped will vary from site to site, but these resources are clearly necessary for the field.
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