The struggle for hospitalists to maintain a balance between teaching duties and clinical demands
by Gretchen Henkel
As clinicians and educators, academic hospitalists function within several arenas: They are role models and teachers in the inpatient arena, but they also feel pressure from hospital administration to meet throughput and capacity goals. In addition, hospitalist clinician-educators are expected to be leaders in quality improvement.
But are the rewards for academic hospitalists commensurate with the demands placed upon them? Even as hospitalists prove their worth to hospital administrators, many clinician-educators find themselves pulled between time spent on service and time for the academic pursuits necessary to improve resident education and merit faculty promotions.
“In my current situation, there is difficulty in fitting in the prep work time for teaching rounds,” says Elizabeth A. Schultz, MD, who practices with the Adult Hospitalist Team at Swedish Medical Center in Seattle and is also affiliated with the University of Washington School of Medicine. “There’s really no time for that, other than time on my own—and I’m actually in a really good situation right now where my boss has capped the number of patients I see in a day and afforded me the ability to go to conferences, do teaching rounds, and to really focus on resident and medical student education.”
Dr. Schultz is not alone in struggling to balance clinical and educational duties. Many hospital medicine leaders wrestle with these concerns, aware that growing clinical responsibilities impinge on teaching time and that the sustainability of hospital medicine as a career is at stake.
An October 2006 survey by the University HealthSystem Consortium confirmed that hospitalists have improved the educational process for residents and medical students, but it also identified impediments to the continuation and growth of hospitalist programs. (The Benchmarking Study, “Role of the Hospitalist,” is available online to University HealthSystem Consortium (UHC) members and registered website users at www.uhc.edu.) The most common barrier is the difficulty in attracting and retaining quality candidates, given the ratio of salary to workload, the potential for burnout, and undefined career paths.
“There is a significant amount of demand on one small group of physicians, and we haven’t necessarily found a way to compensate them for the different roles they play,” reflects Alpesh Amin, MD, MBA, FACP, associate program director for the Internal Medicine Residency Program and the medicine clerkship director at the University of California at Irvine (UCI), where he founded the UCI hospitalist program in 1998 and serves as its executive director. “These three arenas that hospitalists have to constantly keep moving in are not always complementary. How do you spend more time facilitating the teaching mission versus time facilitating the throughput mission or the expanding clinical mission?”
Meeting goals for academic appointments adds yet another layer of role conflict, he notes.
Sylvia Cheney McKean, MD, FACP, medical director of the Brigham and Women’s Hospital/Faulkner Hospitalist Service in Boston and chair of SHM’s Career Satisfaction Task Force, also acknowledges the tensions between clinical duties and academic pursuits. “If you have 20 patients to see and discharge and yet you also have a grant to write, guess what’s not going to get done?”
To be fair, academic hospitalists experience their situations in different ways. Kathleen Bradford, MD, the inpatient director of the University of North Carolina (UNC) Children’s Hospital, director of the Pediatric Hospitalist Program, and assistant residency director for the Division of General Pediatrics at UNC in Chapel Hill, N.C., has not experienced a huge conflict between her teaching and clinical duties, but she has noticed that there are fewer opportunities for teaching, given the increased clinical demands on physicians and the decreased availability of residents.
“I’ve always felt that medicine—and especially medical teaching—is like an apprenticeship,” she explains. “There are many, many opportunities to teach while doing in an apprenticeship-like fashion. The demands of taking care of patients and [reduced] resident work hours have certainly decreased the ability to do more formal and didactic or classroom-type teaching. However, the opportunities for spontaneous or ‘teach as you go’ education still exist.”
Dr. Schultz, a member of the Swedish Medical Center’s teaching service who leads a teaching team every month, admits she has no answers to the time crunch academic hospitalists experience. “There just isn’t enough manpower,” she says. “The hospital doesn’t get paid for people to teach, and to pay people to have dedicated time to pursue academic research or prepare lectures just isn’t feasible for most hospitals, as they are already struggling to make ends meet.”
Many hospitals employ both non-teaching and teaching services to ensure night and weekend coverage. But this can create other dilemmas for the academic hospitalist. For instance, Dr. Schultz says her teaching service gets the more complicated and critically ill patients who require more of her time, thus squeezing out, again, the opportunity to prepare lecture notes or conduct research.
At UNC Children’s Hospital, the pediatric hospitalist program is in its infancy, having launched in fall 2006, and the new service is mostly a non-teaching service. Dr. Bradford reports that the teaching and the hospitalist service are assigning patients on a case-by-case basis. “There is [teaching] value in all patients and all cases,” says Dr. Bradford, “but it’s really hard to say which ones have the most value: Should it be the patient who has a short stay with a common illness or a patient who has been chronically ill and in the hospital for 100 days? It’s hard to know.”
At Brigham and Women’s Hospital, Dr. McKean reports the hospitalist group did not want to institute a two-tiered [teaching and non-teaching] hospitalist program, so one of their hospitalists, Chris Roy, MD, created a Physician Assistant Clinician Educator (PACE) service, with a hospitalist supervising two PAs during daytime hours; it’s supplemented by moonlighters at night. Members of this service have teaching responsibilities and are involved in curriculum development for physician assistants and students. Additional research is needed to examine outcomes of educational efforts directed toward the multidisciplinary team in the core competency areas elaborated by the Accreditation Council for Graduate Medical Education, explains Dr. McKean.
Whatever strategies are used to address case workloads, effecting real change for academic hospitalists—ensuring protected time as well as rewards for educational and research pursuits—will require clear-sighted planning from hospitalist leaders. “The bottom line is to proactively manage the program’s direction and growth,” asserts Dr. McKean. “Instead of being everybody’s Band-Aid and being everything to everybody, it’s important to have a strategic plan. You can’t necessarily plan for five years, but you can plan for three, and you could do things in a step-wise manner to increase the academic and research presence.”
This is precisely where SHM’s emphasis on networking and mentoring can come in, believes SHM’s Education Committee Chair Preetha Basaviah, MD, clinical associate professor of medicine and associate course director, Practice of Medicine, at Stanford University School of Medicine, California. SHM has led many initiatives, such as the publication of the Core Competencies and the creation of Web-based quality improvement resource rooms, which help provide curriculum support.
“What we’ve done as an education committee is to help provide some of the resources, support, and advocacy that our members need so that they can go back to their programs and say, ‘These are the national standards and resources provided by an organization that advocates for us.’ ” says Dr. Basaviah.
Creating a network of hospitalists, both regionally and nationally, provides opportunities to gain protected time for research pursuits and recognition from one’s peers, Dr. Basaviah continues. “I think what we’ve done for clinician educators is to promote thinking proactively about your short-term and long-term career goals, including developing an area of expertise, before you take on commitments,” she says.
Dr. Amin’s role in education at his institution informed his active participation in SHM’s Education Committee, which he chaired for four years, and his role on the Core Competencies Task Force. He believes it is through such initiatives that hospitalists can become leaders in their institutions, participating in curriculum development as well as quality and performance improvement efforts.
“I don’t view myself as just working for the hospital or … for the School [of Medicine]. I view myself as working for the enterprise,” he says. As a result his hospitalist group has taken the lead in designing various residency inpatient curricula. “If you do it right, you could actually design curricula to educate residents about heart failure—teaching them about the pathophysiology and disease management—but then also teach them about core measures, outcomes, and systems-based practice in heart failure,” he says. “When all that comes together, I think you’re making some progress.”
Jeffrey G. Wiese, MD, vice chairman and director of the Internal Medicine Residency Program at Tulane University, New Orleans, is the leader of the SHM Task Force for Integrating Core Competencies into Residency Education. He points to the SHM Academic Task Force’s idea of developing an EVU, or educational value unit, that would define and compensate for amounts of time invested in educational pursuits. He would also like to see SHM take a role in developing standards and recommendations for promotion criteria. These are tools that academic hospitalists could use to “make their case” to medical schools’ residency programs about the value they offer to the institution.
Dr. Wiese is excited about train-the-trainer pre-courses now being designed for SHM’s 2008 annual meeting. These courses, he says, will train academic hospitalists to teach issues that are not only important to residency programs but “right up the alley of the hospitalist: namely, systems of care and practice-based learning.” In this way, he explains, academic hospitalists could have an “exponential effect” on furthering the profession.
Daniel D. Dressler, MD, MSc, director of hospital medicine at Emory University Hospital and assistant professor of medicine at Emory University School of Medicine in Atlanta, is “significantly concerned” about attracting academic hospitalists. The 60+ hospitalists in his group staff five community hospitals (two of which have teaching services) in addition to the system’s tertiary care center. At that hospital, he says, patient acuity is appreciably higher, which means hospitalists must spend more time caring for patients and relating to their family members—time that does not translate into more billable relative value units (RVUs). This type of work environment is definitely “a difficult sell” to potential new hires, he notes. “There is … a balance between patient care and teaching in an academic environment, and maintaining that ‘right balance’ is always a challenge.”
System changes to reward educational prep time, such as the EVU Dr. Wiese mentioned, may be one solution to achieving a patient care/teaching time balance, agrees Dr. Dressler. “I think it’s an excellent idea to have some sort of measure that you can utilize to help reward physicians for putting an emphasis on education—actually promoting and executing educational efforts,” he says. Emory’s program is piloting a mechanism that would objectively measure clinicians’ self-identified efforts to set educational standards. Rewards (e.g., financial recognition or awards for “best teacher” and so on) could be built into the effort, he says.
Hospitalists face an uphill battle to secure funding for research, admits Dr. Wiese: “There is not the same level of NIH [National Institutes of Health] funding for quality improvement that there is for basic science research. And the QI funding that is available does not bring the same salary coverage that the basic science researchers are bringing to the department.”
Hospitalists need to be creative in defining their research agenda and funding streams. Dr. Basaviah says that if hospital medicine leaders emphasize the value of their systems-based quality improvement efforts, they may be able to secure funding for QI research efforts from “the hospital/medical center administration, Department of Medicine, QI group/division, or from residency programs, depending on where their efforts are going to be the most closely aligned.”
Tapping into SHM’s resources can foster community and allow younger hospitalists a method for charting a career path. Dr. McKean’s Career Satisfaction Task Force will soon release a white paper relating to the four pillars of career satisfaction: control/autonomy, reward/recognition, workload/schedule, and community environment. Questionnaires for individual hospitalists and physician leaders will help both groups identify the best job for an individual or the most appropriate person for a position. Included in the group’s analysis of career sustainability and satisfaction are organizational, system, professional development, and marketing-relationship strategies to help hospitalists assess job satisfaction. It is the task force’s hope that the document can be a useful tool in interactions with hospital administrators as well, to demonstrate the elements necessary for staff satisfaction and retention.
“A surgeon would never operate without a multidisciplinary team in the operating room,” says Dr. McKean. “And yet, because they’ve done order entry, they’ve done resident-level duties, hospitalists across the country are expected to step up without any resources to meet service demands relating to a shortage of residents and high census conditions. Performing residency-level duties not only undermines job satisfaction but also [affects] how efficiently hospitalists can care for a large number of patients. Hospitalists need to be given the tools to be efficient and improve the quality of care in the hospital.”
When asked what keeps him in academics despite lower remuneration rates, Dr. Wiese expresses the same sentiment as his colleagues: “It’s all about fulfillment. I like interacting with people and seeing them get better. If you train residents in the right way and then train them to train others, then suddenly your affect in improving quality of care and education has an exponential effect around the country.”
Dr. Dressler agrees. “Obviously, not everyone wants to do academic medicine, and you must have some interest in teaching and training others,” he says. But more important than financial remuneration, he notes, is “overall job satisfaction and being happy with the people you work with, as well as the patients you’re taking care of and the teaching that you’re doing.” That’s why hospitalists and faculty should work toward building recognition into the system. Hospitalist leaders can advocate for the mechanisms necessary, “to make sure that physicians also have time to have a life, to relax, and to enjoy their profession,” says Dr. Dressler.
“When I hire hospitalists, my goal is to hire people interested not only in good quality, efficient inpatient care but also in teaching,” said Dr. Amin. “I will easily tell them that they can probably make more money and have a better lifestyle working as a community hospitalist if they don’t want to deal with this other mission [of teaching].”
“I think if we view our work as just a job rather than as a career or profession that can be fulfilling, we may be led to paths of potential burnout,” said Dr. Basaviah. “Many of us view the healthcare profession with a notion of service and a vision for a satisfying career. I think that it’s important for all of us to facilitate the ability of our colleagues to thrive in these careers.” TH
Gretchen Henkel has written for The Hospitalist since 2005.
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.