A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”
Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.
—Vineet Arora, MD, MA
Six Ways to Shape Your Residency Toward Hospital Medicine
1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”
A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.
2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.
“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”
Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”
Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”
Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”
The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”
3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.
She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”
Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.
4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).
“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”
Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”
Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”
5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.
“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”
Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”
6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)
“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.
Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.
Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH