A seven-step program to address the issues plaguing teaching hospitalists
by Jeff Glasheen, MD, SFHM
If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.
Are hospitalists happy? Are we satisfied, stressed, burned out? How is this impacting our field? What can we do about it? The Hospitalist this month takes a hard look at the often overlooked issue of career satisfaction and its cousins burnout, stress, and turnover.
After a decade of taking a fly-by-the-seat-of-our-pants approach to building, managing, and remediating HM programs, we finally have some concrete data to help guide us in building our programs. In fact, no fewer than three research papers studying these issues have been published recently—two of them from my institution.1,2,3 As such, I’ve been thinking about this a lot and what this means to the field in general and, more specifically, academic hospitalists.
Now I recognize that academic hospitalists make up but a fraction of the hospitalist work force; nonetheless, I believe it is an important fraction, even for community hospitalists. As I’ve written before, HM’s pipeline is dependent upon future hospitalists (commonly referred to as residents and students) engaging with fulfilled, satisfied, and successful academic hospitalists—the kind of specialists that look and feel like other specialists. If today’s learners interact with grumpy, overworked, unsatisfied, marginalized intern-extenders, they will quickly up-regulate the gastroenterology gene, and the best and brightest will start to flow out of our pipeline.
So what do these studies show? How do we assimilate these data into our programs, and how can we use it to produce more sustainable, effective, and productive academic HM groups? Here’s my take: a seven-step prescription of sorts for what ails academic HM.
I was having dinner recently with a higher-level executive with a national hospitalist management company that primarily staffs community hospitals. An uncomfortable pause, followed by gasping sounds, ensued after I told him our starting academic salary. After collecting himself, he asked how on Earth I could recruit hospitalists at such a low salary—I think hoping to discover the fount to lower personnel costs. Simply put, some people are willing to sacrifice salary for the academic mission and all its trappings.
In fact, the only differential advantage academic programs have over their community brethren is the ability to be, well, academic—that is, to teach, develop, innovate, disseminate, and create the knowledge base that fuels our specialty. The academic mission is not for everyone. But there is a pool of individuals who are willing to forego financial compensation for compensation of a different sort. Take away the academic mission, and the two jobs start to look similar, salaries equilibrate, and people with academic leanings become unsatisfied.
And burned out. I’d argue that career-fit mismatch is a main cause of academic hospitalist burnout—I come to academics to be academic but find in turn a community job in a teaching hospital. This is supported by data showing that 75% of academic hospitalists described their primary role as either teacher or investigator, yet most (52%) spent 40% or less of their time with learners, and 57% had 20% or less of their time protected for scholarly pursuits.1 This epitomizes career-fit mismatch, and likely explains why nearly a quarter of academic hospitalists are burned out.
An extension of this idea is that academicians need time for scholarship. In fact, academic productivity cannot be measured in wRVUs alone. Don’t get me wrong; hospitalists need to support their salaries and see lots of patients. But teaching the next generation, developing and disseminating knowledge, and generating a promotable academic portfolio takes time—time that can’t be shoe-horned into 200-plus busy clinical shifts a year. This is supported by evidence showing that more than 20% of protected non-clinical time was one of the biggest predictors of academic productivity.2
Five thousand wRVUs? Way too much. Four thousand? Getting warmer. Three thousand? Try a little lower. I’d go out on a limb and say the right number is slightly below 3,000 wRVUs.
I suspect this will raise some eyebrows among hospital administrators who fund these programs—and I welcome the letters. But before you pick up your pen, consider this: What is the value of educating our future physicians (something most teaching hospitals are funded to do through graduate medical education dollars), discovery, scholarship, hospital quality improvement (QI), and sustainable faculty careers? Academic hospitalists have decided to value it with a pay cut. Are our administrators willing to make a similar sacrifice?
Protected time comes with a responsibility to produce. Discovering, publishing, speaking, and presenting are hard work—so hard that the default of not doing it presents an all-too-often-enticing option. This in part explains why most academic hospitalists have not published a first-author, peer-reviewed paper (51% have not), given institutional medical grand rounds (74%), or presented at a national meeting (75%).1
This is where cultivating a group culture of scholarship replete with expectations (# of publications/year), opportunities to present work (hospitalist Grand Rounds), faculty development, mentorship and institutional support (financial commitment and time to teach) are paramount.
Let me emphasize that last point. The majority of academic hospitalists lack formal fellowship training and, therefore, are not going to be funded or promoted based on research outputs. In fact, more than 90% of hospitalists will be promoted (or not) through the clinician-educator pathway. That means our academic currency is teaching and curriculum development.
That’s why the majority of academic hospitalists spending the majority of their time on non-teaching services is a major problem. It’s akin to an eternally unfunded researcher trying to get promoted as a clinician-investigator. It’s not going to happen.
Duty-hour restrictions, growing hospital services, PCP exodus from our hospitals, and the growth of comanagement are driving further hospitalist expansion in teaching hospitals. This means more mouths competing for a shrinking teaching pie. I don’t have the solution, but I suspect that those clinician-educators spending less than 25% of their time with learners will find it difficult to be sated, successful, and promotable in academia.
Mentorship unquestionably is tied to publications, presentations, grant funding, job satisfaction, and, ultimately, academic promotion. Yet only 42% of academic hospitalists report having a mentor.2 Of those with a mentor, the vast majority spend less than four hours a year with their mentor.2 I can identify no more obvious and urgent problem to solve in academic HM.
The single most powerful predictors of burnout and low satisfaction are a lack of work/life balance, autonomy, and control over one’s work environment. In fact, control over work schedule (odds ratio 5.35) and amount of personal time (OR 2.51) were the biggest predictors of burnout for academic hospitalists. Similarly, control over work schedule (OR 4.82) and amount of personal time (OR 2.37) predicted low satisfaction.1 The bottom line is that flexibility, autonomy, and control are essential components to academic fulfillment.
There you have it—a prescription for success.
Well, it turns out we are still missing one thing—one final ingredient, something mysterious and all-too-often lacking. A magic potion that allows for the right people to be in the right places with the right tools to succeed. With it, our potential knows no bounds. Without it, we’ll continue to struggle. In fact, its absence is one of the single biggest predictors of low satisfaction for academic hospitalists.1
What is “it”?
HM needs individuals to fill this prescription. The problem is that our leaders are often young, inexperienced, and raw. They are tasked with creating positions with an academic focus, reasonable clinical productivity expectations, a culture that promotes scholarship, sufficient non-clinical time, adequate time with learners, robust mentorship, and ample autonomy, work-life balance, and a chance to grow. To do this, they need direction, mentorship, a peer network, and skills development.
At least that’s what I need.
In fact, come to think of it, I think there is an eighth step for academic success—the need to develop an external academic peer network, to grow together, to actively engage, and depend on for help. As such, I hope you’ll partake in step No. 8 with me—at HM12, Academic Hospitalist Academy, Leadership Academies, and the Academic Summit. I hope to see you soon.
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program. He is physician editor of The Hospitalist and course director of the SHM’s 2012 annual meeting (www.hospitalmedicine2012.org).
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.