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.
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.