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Underwater Breathing


It’s fall. I know that because the leaves are turning, the nights are chillier, and my dogs have migrated back to the bed from a hot summer on the floor. Oh, and I again need to fill four positions for my hospitalist group.

A lot has changed in HM recruiting in the past few years. There was a feeding frenzy in the early part of the century, when I often joked that group leaders were so desperate for boots on the ground that my mom (who is not a physician, is retired, and struggles somewhat with the triple acid-base disorder) could have gotten a job as a hospitalist. I saw it in the number of reference calls for the residents in our program, their ever-increasing salary offers, and the breathless e-mails I’d receive from headhunters. Improbably, on occasion, their froth would even boil over to an offer for me, an academic. Now that’s desperation.

But things seem to be changing. The number of calls per resident is down and my inbox is filled with slightly less-winded recruiters. Maybe groups have finally matured and don’t need to hire; maybe the recession has induced an air of caution around growth; or maybe groups have uncovered the secret tonic to seeing more patients with fewer providers. Whatever it is, it seems that the job market has tightened ever so slightly.

And the job market has changed, especially on the academic side.

Come work for us, do the same work you’d do at a community hospital, in a less-efficient system, without residents, for a lot less money.

Work Harder for Less

In academics, we hire into jobs we describe as “clinician-something,” with the something reflecting what you do when you are not seeing patients, the thing that in most cases will get you promoted from instructor to assistant to associate to professor. Because HM is not a fellowship-driven field, primary researchers, called clinician-researchers, are rare. Most of the folks we hire fall into the clinician-educator mold—that is, they see patients and teach, develop curriculums, and produce scholarship, often around education.

And therein lies the problem.

We’re running out of educational opportunities. The demand for clinical work long ago outstripped the supply of teaching opportunities, resulting in many academic HM groups hiring hospitalists for clinical jobs without residents to teach. Much like a deep-sea diver miles below the surface who finds his oxygen tank is running low, we now find ourselves looking up at an ocean of patients and realize that our educational lifeline has been severed. And the dyspnea is becoming ever more uncomfortable.

Increasingly, here is the sell for many academic HM groups: “Come work for us, do the same work you’d do at a community hospital, in a less-efficient system, without residents, for a lot less money.” And because you are primarily a clinician, you probably won’t have protected time to develop an academic interest and, therefore, you won’t get promoted beyond the “instructor” level because you haven’t contributed to advancing your field of medicine.

Even my mom wouldn’t apply for that job.

Failure Does Matter

The academic hospitalist job circa 2010 is heavy on the hospitalist and light on the academic. This is bad. And it matters to all of us, community hospitalists included. Without a strong frontline of academic hospitalists, we will not develop this field beyond “doctors who work in a hospital.”

There is a science to our field and it needs to be further developed. It can be seen in the comparative-effectiveness research, which tells us the best way to manage common diagnoses, the translational research (i.e. getting that new drug from the bench to the bedside), and the systems-based improvements (e.g. ensuring every stroke patient gets thrombolytics within three hours).

Take readmissions. There is a lot of dyspepsia swirling around this issue, and it’s clear that we have to reduce them. In fact, without such reductions, our hospitals (and likely us) won’t get paid. How will we do that? Maybe Project RED, maybe Project BOOST, maybe the best solution hasn’t been found yet. We don’t know, and we won’t until academic hospitalists have studied it.

Moreover, if we don’t present learners with talented, satisfied, respected hospitalist role models, I guarantee you that the quantity and quality of residents graduating to academic and community HM programs will suffer. Think back to those people who lured you into your specialty. Were you inspired to pediatrics, family medicine, or internal medicine because you saw those providers toiling away unsated by themselves on the wards?

Academic HM has a problem. And we are working toward the solution.

Six months ago, 90 academic hospitalist leaders convened in Washington, D.C., for the first Academic Hospital Medicine Leadership Summit. The goal was to develop a vision and action plan for the future of academic HM. Three work groups tackled the research, educational, and clinical issues facing our field. The recommendations of these sessions were then transferred to SHM’s Academic Committee and its subcommittees for operationalization.

A Pipeline of Quality

The education work group identified a need to establish hospitalists as the teachers of quality and safety for students and residents. This included increasing the number of hospitalists in such educational leadership positions as program and clerkship directors, where they can visibly lead the educational infrastructure. In response, SHM will unfurl the Quality and Safety Educators Academy this spring with the goal of providing academic hospitalists the construct to teach quality and safety.

Additionally, SHM’s Education Committee is developing a “plug and play” quality-improvement (QI) curriculum for use by any hospitalist educator. These initiatives will build on the success of the Academic Hospitalist Academy, developed two years ago to provide early career direction to academic hospitalists.

The education work group also prioritized the development of a strong pipeline of interest in HM starting at the medical-student level. This recommendation was turned over to the newly minted Pipeline Committee, which has been working feverishly to develop and expand medical student Hospital Medicine Interest Groups, the development of HM residency tracks, and an extension of our partnerships with other educational groups.

Answers to Future Questions

On the research front, goals were set to better develop and support clinician-researchers. This includes better delineating HM core research strengths, devising methods to partner with other medical subspecialties to perform quality and safety research in their areas of content expertise, and to develop a pipeline of future researchers.

To this last point, SHM awarded its first set of $50,000 research awards to two burgeoning researchers earlier this year.

SHM also is partnering with the Association of Specialty Professors to offer career development grants in geriatric medicine through the new Grants for Early Medical and Surgical Subspecialists’ Transitions to Aging Research (GEMSSTAR) program. And for the rest of us, SHM has devised free, Web-based forums for young researchers to present their work to their peers nationally.

Productivity, Efficiency, and Promotion

On the clinical side, the needs addressed include identification of benchmarks for academic clinical productivity, pathways for academic promotion, a methodology to garner more support for nonclinical work, and expectations to improve workflow and efficiency in academic medical centers.

These important tasks were assigned to a newly created Academic Practice and Promotions Task Force. This group is actively developing a quantitative survey to evaluate these needs and plans to publish a white paper of their findings, along with recommendations for hospitalist program directors, their department chairs and deans, and the hospitals that fund their programs. The findings will be presented at the next summit—at HM11 on May 10, 2011, in Dallas—as we continue to chart the course for success in academic hospital medicine.

Until then, I need to get my tank refilled. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

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