Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville, Tenn., was working in the emergency department when a woman arrived with an asthma exacerbation. The woman, who spoke only Spanish, had been hospitalized just five days earlier for asthma, and hospital staff had given her discharge instructions through her husband. Speaking to the patient in Spanish, Dr. Kripalani soon learned something had been lost in translation: The patient had not taken any of the prescribed prednisone tablets, and instead was taking a burst of montelukast. She also was taking a long-acting bronchodilator every two hours instead of every 12, and she was incorrectly using her rescue inhaler.
As the principal investigator of a trial aiming to reduce post-discharge adverse events and emergency room visits, Dr. Kripalani knows well the issues that contributed to the patient’s re-hospitalization.1 Through research, he and his colleagues hope to prevent future cases.
“It’s very rewarding to identify problems in the care of hospitalized patients and then develop and evaluate interventions to solve those problems,” says Dr. Kripalani, a 2001 graduate of the Emory Mentored Clinical Research Scholars Program who also leads Vanderbilt University’s hospital medicine fellowship. “Sharing those solutions with colleagues so they can be applied to patient care at my institution and others brings the research full circle.”
As the field of hospital medicine grows, the number of hospitalists moving into research careers is expanding, says Peter Kaboli, MD, MS, associate professor in the Department of Internal Medicine at the University of Iowa and a 2001 graduate of the Veterans Administration Quality Scholars Fellowship program. Research training programs, or fellowships, put hospitalists on the path to new skills and position them for careers in academic medicine and other leadership positions, Dr. Kaboli says. Training programs also put fellows in contact with mentors who provide valuable guidance.
Although there are dozens of general internal medicine (GIM) fellowships available to hospitalists, few programs are specifically designed to train hospitalists in research. “Hospital medicine is still a relatively new field,” Dr. Kaboli explains. “The field still does not have many research training options that are separate from general internal medicine.”
Still, hospitalists have advanced training choices, and, depending on their interests, can pursue field-specific programs or follow a general internal medicine path.
Many hospitalists receive basic research training from GIM fellowships. Once they have a research foundation, they can take their experience in another direction.
“Some physicians use their clinical interest—hospital medicine—as the platform for their research,” Dr. Kaboli says, using his own resume as an example. “It’s a nice synergy—doing research in a clinical area of interest.”
Physicians interested in fellowships often start looking for opportunities before they complete their residency, or immediately after. The transition makes sense for some; they move from one academic setting to another. Others, however, consider fellowship programs after they have spent some time in practice and get what Dr. Kaboli calls “boots-on-the-ground experience.”
“I think this is an area where there is potential for growth,” Dr. Kaboli says of physicians returning to fellowship programs after years spent in practice. “It’s the equivalent of a businessperson going back to school to get an MBA. They say, ‘Now I understand what this job really means, and I want to do more.’ ”
The caveat is a pay cut. Physicians in fellowship programs generally are paid a stipend of about $50,000 a year, Kaboli says. By comparison, the average hospitalist makes about $193,000 per year, according to SHM’s 2007-2008 Bi-Annual Survey on the State of Hospital Medicine. For two years, fellows devote their lives to training, coursework, and research, and spend only about 25% of their time treating patients, he says.
Road to Research
Hospitalists can choose from a range of general internal medicine fellowships at universities, clinics, and medical centers across the country. Each program offers something different; the fit depends on the candidates’ interests, says Geri Barnes, SHM senior director of education and meetings. For instance, training programs offer advanced study in the areas of biostatistics, epidemiology, and research methodology, to name a few. GIM fellowships (see “To Be or Not to Be a Fellow,” May 2006, p. 26) encourage scholars to develop relationships with mentors to guide them through research projects, she explains. A program’s duration can span one to three years. Some programs give fellows the opportunity to earn an advanced degree in quality improvement, clinical research, public policy, health studies, public health, or clinical epidemiology.
A handful of institutions, including Johns Hopkins Hospital in Baltimore, offer GIM fellowships with a hospital medicine emphasis. The National Institutes of Health (NIH) funds the Johns Hopkins program with training grants, says Daniel J. Brotman, MD, director of the hospitalist program there. GIM leadership is taking a “big tent” approach, promoting the development of hospital medicine tracks within the full program, which is good for the fellowship and for the hospitalist program, Dr. Brotman says.
“Some of the challenges for hospitalists are that they are generally young and don’t have the skills to succeed in academic medicine,” Dr. Brotman says, “and the number of mentors in hospitalist medicine is few and far between. [The fellowship] allows scholars to tap into experienced research mentors who may not be hospitalists themselves but are interested in investigating research questions and promoting academic careers in hospitalist medicine.”
The GIM program at Johns Hopkins draws physicians trained in internal medicine as well as general medicine/pediatrics. Candidates are required to have completed an internal medicine or medicine/pediatrics residency and must provide strong letters of recommendation. Scholars receive training in statistical methods while obtaining a master’s degree in public health or health science at the Johns Hopkins Bloomberg School of Public Health. Fellows commit 80% of their time to research and research training, and 20% of their time to clinical duties; they are expected to form relationships with faculty, which ultimately leads to careers in academia or public health, Dr. Brotman explains.
Physician burnout—so common in the current healthcare system—is an excellent reason to consider a research career. Five years ago, David Meltzer, MD, PhD, an associate professor in the Department of Medicine at the University of Chicago, wanted to increase the number of research-trained hospitalists, so he moved to create a hospitalist training program. Around the same time, the hospital approached Dr. Meltzer and others, asking them to expand the number of clinical physician positions.
“We were afraid the new physicians would burn out rather quickly if their jobs included only clinical work,” Dr. Meltzer says. “We designed positions that had less clinical work but more time for physicians to develop research skills to support sustainable academic careers.”
Hospital leaders agreed, and the university’s Hospitalist Scholars Training Program was born. The two-year curriculum trains hospitalists for a career in academic research, and combines inpatient clinical work, coursework, and mentored training related to an academic project. Scholars typically leave the program with a master’s degree in public policy or health studies.
“Most of our graduates are working in academic research,” Dr. Meltzer says. “The program has been a great source of new faculty for us.”
Short-term programs are available in select topics. For example, the University of Chicago offers a summer program in outcomes research training for hospitalists interested in careers in health research, Dr. Meltzer says. SHM and the Agency for Healthcare Research and Quality have provided funding to expand the program to include as many as six hospitalists from around the country.
Applicants from any medical or surgical specialty are eligible to apply for the Robert Wood Johnson (RWJ) Clinical Scholars Program, the nation’s oldest research training program for physicians in health services, research, and leadership.
“The mandate of Robert Wood Johnson is ‘health and healthcare for all Americans,’ ” says Desmond Runyan, MD, DrPH, national program director of the RWJ Clinical Scholars Program. “We give physicians the skills they need to be leaders, and then we push them out the door so they can go out and shape the future of healthcare in this country.”
Applicants must be U.S. citizens and, with the exception of surgeons, must complete their residency training before entering the clinical scholars program. The two-year program offers a master’s degree in graduate-level study and research, and scholars may be considered for a third year of support. Scholars have their choice of four training sites: the University of California at Los Angeles; Yale University in New Haven, Conn.; the University of Pennsylvania in Philadelphia; or the University of Michigan in Ann Arbor.
Programs vary, but each university has a curriculum to teach the basics of healthcare research. It also provides protected time for research; about 20% of time is spent on clinical activities, according to the program’s Web site. Graduates receive leadership, health services, and community-based research training.
The RWJ Foundation spends about $9 million per year on the program, which covers research support, salaries for scholars and program administrators, travel, and other expenses. About half of the program’s graduates go into academic positions; the other half go into public health or other leadership positions. One recent graduate opted for a position in quality control; three other graduates serve as staff in the U.S. House of Representatives and the U.S. Senate, he says. Other graduates work with foundations, state and federal health agencies, or with companies working in the healthcare industry.
“This program looks for people who don’t march to a standard drummer,” Dr. Runyon says. “We are looking for risk-takers who want to make a difference.”
The Veterans Administration National Quality Scholars Fellowship Program (VAQS) welcomes physicians from all medical specialties, including pathology, OB/GYN, surgery, and dermatology. This year, the program will begin recruiting nurses.
The program is offered at six academic-affiliated VA medical centers: Iowa City, Iowa; Nashville, Tenn.; Birmingham, Ala.; Cleveland; San Francisco; and White River Junction, Vt. The Iowa City and Nashville programs have a track designed specifically for hospitalists. These tracks focus on clinical research and quality improvement work in the inpatient setting, and provide fellows with training for advancement in academic and private-sector hospitalist careers, says Dr. Kaboli, the Iowa City VAQS Fellowship director.
To qualify, fellowship applicants must have completed an Accreditation Council for Graduate Medical Education residency or fellowship (see “A Pregnant Pause: The necessary evolution of residency training,” January 2007, p. 35), be board-eligible or board-certified, and have an active, unrestricted U.S. license to practice. International graduates must meet visa and Educational Commission for Foreign Medical Graduates requirements.
The two-year VAQS focuses on quality improvement in healthcare, Dr. Kaboli says. The program offers master’s-level training in epidemiology and biostatistics, and trains fellows to design and conduct research and improvement projects. Fellows publish the results of their research in peer-reviewed journals. They also learn how to write grants to gain funding for future projects.
Mentoring is an important element of the VAQS program, Dr. Kaboli says, adding that the value a trainee receives from any fellowship depends on the level of mentoring available through the program. Fellows work with senior faculty members who provide guidance on all aspects of research, Dr. Kaboli says. This includes study design, research methodology, data collection and analyses, and writing.
New experiences and the opportunity to take part in research are among the benefits of completing the VAQS program, Dr. Kaboli says. Some physicians also find a great deal of career satisfaction through research.
“I love seeing patients,” Dr. Kaboli says, “but I also like the challenge of doing research to find new ways to improve patient care.” TH
Gina Gotsill is a freelance medical writer based in California.
1. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowship: works in progress. Am J Med. 2006;119;72.e1-72.e7.