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Quest for Independence


 

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

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