Five years ago, a medical resident interested in pursuing a career as a hospitalist had few opportunities to receive specialized training. Five years from now, residents likely will have numerous hospitalist training tracks and electives from which to choose. This is partly thanks to a small group of pioneers who have seen the value of specialized hospitalist training for residents. These individuals have carefully considered what skills, information, and experience residents need to practice as confident and competent hospitalists, and they have developed programs and courses that meet these needs.
Sharpening Residents’ Focus
“Actually, we don’t call them ‘tracks,’ ” says Andrew Rudmann, MD, assistant professor of medicine and chief of the Hospital Medicine Division at the University of Rochester Medical Center. “We don’t want students to think that they’re stuck in an area once they choose it.”
Nonetheless, he notes, students increasingly are choosing careers as hospitalists, and they are expressing an interest in gaining skills and knowledge to help them become hospitalists.
Dr. Rudmann adds that his students “are sorting out their career plans earlier,” so it is important to offer specialized focus area programs. He has divided these into three areas: general medicine inpatient (hospitalist), general medicine outpatient (primary care), and subspecialty (other specialties).
The focus area programs are still in the developmental stage, Dr. Rudmann stresses. “We are in the process of developing the curricula for these programs, all of which will be elective experiences,” he says. Determining course options will be a challenge because there are a limited number of hours available for these electives. Nonetheless, Dr. Rudmann has identified several activities essential to producing effective hospitalists. These include:
- Rotation at a community hospital. “This program will focus on communication issues with primary care physicians,” explains Dr. Rudmann. “The students also will spend time in primary care offices to focus on the transition of patients from hospital to community care.”
- Quality improvement (QI) project. Residents will work one-on-one with hospitalists and develop a QI project from their work that they will present at the end of the rotation. As hospitalists, says Dr. Rudmann, these individuals frequently will be involved in QI initiatives and committees, and it is important that residents be prepared for these activities.
- Billing, coding, documentation mentorship. Each student will have a mentor, who will be required to instruct residents (either one-on-one or in small groups) about these issues. While billing, coding, and documentation are not glamorous, they are important components of a hospitalist practice, so Dr. Rudmann wants to ensure that residents are comfortable handling these activities.
Hospitalist students also will have the opportunity to spend time shadowing healthcare professionals in other areas such as the detox unit and bronchoscopy suite.
“It’s useful for a resident to spend time learning what these people do and what happens in these areas,” says Dr. Rudmann. “Our current healthcare system tends to be fragmented, and this experience will help physicians ensure smooth transitions for patients from one site to the next.”
Dr. Rudmann says he will suggest that residents interested in being hospitalists spend time in the ED observation unit. Additionally, these residents will be exposed to patient safety and medico-legal issues through active participation in morbidity/mortality conferences.
Residents also will have the opportunity to take a research elective course. However, Dr. Rudmann notes that students will need a real interest or passion for research to participate in this option, as it will consume one-half of their elective hours.
Day in the Life
Providing exposure to many of the day-to-day aspects of hospitalist practice is a key component of the hospitalist elective program at Emory University in Georgia.
“We wanted to provide residents with an opportunity to get some clinical exposure that they don’t necessarily get during general residency training and give them a better sense of what hospital medicine is—aside from taking care of patients in the hospital,” says Dan Dressler, MD, MSc, director of hospitalist medicine at the Emory University School of Medicine (Atlanta).
Emory’s hospitalist electives also give residents an opportunity to “pick the brains” of hospitalists. “They get to ask about things like schedules, committee involvement, research activities, and so on,” explains Dr. Dressler. “Residents really like this opportunity. They can feel isolated in the academic setting, and this really broadens their horizons.”
Building a Hospitalist Track from the Ground Up
In developing Emory’s hospitalist elective program, Dr. Dressler sought guidance from colleagues at the University of California at San Francisco and the Mayo Clinic (Rochester, Minn.) who already had established specialized hospitalist education opportunities.
Still, developing a good program is not as easy as copying someone else’s efforts. In fact, Dr. Rudmann says that most of the ideas for Rochester’s program came from “a thorough self-examination process.”
“You don’t have to look far,” he explains. “Just look at your own program and talk to your own residents.”
One of the challenges of developing a hospitalist track is the limited time available for elective programs. Dr. Dressler suggests starting by “assessing what you already are doing in your general residency program. You don’t want to duplicate efforts. Determine what is being done well at your program already and what could be done additionally—either based on what others are doing or what should be considered core competencies in hospital medicine. Then implement the missing pieces.”
Even after all of these planning and self-examination efforts, Dr. Dressler cautions, “you probably won’t have enough time to do everything you want to do.” At this point, he suggests concentrating on those issues or skills for which “you have someone who is able and willing to teach and teach well.” For example, he suggested, “if you want to include training on QI but don’t have anyone who can teach this well, you might want to keep this as a goal for down the road.”
Problem-Solving as a Goal
Sometimes, hospitalist training programs can help solve a specific problem. For example, Jason Gundersen, MD, director of the Family Medicine Hospitalist Service at the University of Massachusetts Medical Center, saw that “facilities often don’t want to hire family physicians as hospitalists because they lack hospital experience. [So I] wanted to give family practice residents extra training and experience in hospital medicine.”
The result was a hospitalist fellowship program, the goal of which “is to help improve employment opportunities. It enables graduates to go to employers with specific hospital medicine training,” says Dr. Gundersen. “This gives family physicians more experiences and abilities so they can navigate an uncertain market more successfully. There is a growing interest in hospitalist opportunities on the part of family physicians, and we need to prepare them to fill these roles.”
Despite the growing popularity of hospitalist training tracks and the enthusiasm many express about them, there are people who do not believe these programs are important or necessary. John Ford, MD, MPH, assistant professor of medicine at University of California at Los Angeles’ (UCLA) David Geffen School of Medicine, agrees.
“The first thing you have to understand is that internal medicine residency programs involve a tremendous amount of inpatient care anyway,” says Dr. Ford. “And a lot of what residents do is take care of hospital patients, so this training is adequate for a career choice as a hospitalist.”
“With the rise of hospitalists, people think that we need to emphasize hospital training more. But our residents already do a tremendous amount of hospital training,” he explains. “They do wards, ICU, and CCU; and even many of their electives—infectious disease and cardiology, for example—involve inpatient care. In addition, all of our residents have night float responsibilities, so they cover overflow patients and are in the hospital all night. We are training people pretty solidly for hospital practice.”
Dr. Ford believes it would a mistake for a resident to replace an ambulatory care rotation with a hospitalist track because he or she wants to be a hospitalist. “There is no question that hospitalists save money, lower lengths of stay, and improve patient outcomes and satisfaction,” he says. “But anyone can be a hospitalist. We aren’t an elite group of people.”
It is best to give hospitalists broad training, insists Dr. Ford, because “they still will need the actual job experience of working as a hospitalist to be effective in that role.” He adds that lack of a hospitalist program at UCLA in no way hurts his residents: “We are conventional here, but we do a superb job of education and training. Our residents are not at a disadvantage.”
His advice to residents who want to be hospitalists? “Pay attention—learn to do ambulatory medicine really well. This will help you tremendously when you perform as a hospitalist,” he explains. “You will have better sense of when someone can be discharged and who doesn’t need to come into hospital in the first place.”
Does Hospitalist Training Make a Difference?
“The feedback we’ve received so far makes it clear that this type of training helps people understand hospital medicine and better determine where they want to practice,” says Dr. Dressler. “Residents also have said that they like the variety of exposure to community settings. They said that they learned about activities and issues that they didn’t realize were part of physicians’ responsibilities, such as quality improvement and committee work.”
Dr. Dressler says that his health system has benefited from the program as well. “We have had some good residents stay to practice at one of our hospitals because their hospitalist training was such a positive experience,” he states.
Emory’s program has been in existence for only a few years. And while the number of participants remains small, Dr. Dressler says interest is growing: “We get about 5%-10% of residents in any given year. We are pleased with the turnout, and it has become more popular.”
Way of the Future
“We feel that all of this additional preparation is in our residents’ best interest,” states Dr. Rudmann. “We think it will be popular. Our residents are excited about it already.” He predicts that before long there will be many such programs around the nation. “Residency training programs will use these to gain a competitive edge to attract the best students.” TH
Writer Joanne Kaldy is based in Maryland.