Through their integral role in patient care, hospitalists are uniquely situated to identify problems on medical wards and to design research interventions to address these issues. Clinicians who’ve gone down this path have found it incredibly rewarding but emphasize that education and mentoring are crucial steps to research success.
Looking at why
A research career for hospitalists starts with the question, “Why?” Researchers often share three common characteristics: curiosity, attention to detail, and creativity, according to Chris Bonafide, MD, MSCE, (@chris_bonafide), associate division chief for research integration in the general pediatrics division at the Children’s Hospital of Philadelphia, and associate professor of pediatrics at the University of Pennsylvania in Philadelphia. This includes wanting to speak to clinicians, patients, and the families who are affected most by the issue, and a willingness to view research “outside the box.”
“In my experience, these sorts of skills have predicted a lot of success both in researchers as well as research staff,” he said.
The type of research initiated by hospitalists can vary widely. Margaret Fang, MD, MPH, MHM, division chief of hospital medicine at the University of California San Francisco Health, and director of research and the University of California San Francisco academic hospital medicine fellowship, originally wanted to be a clinician educator, but a quality-improvement elective during residency made her realize the importance of research skills. A project to improve inpatient heparin administration was her first experience running a study. “It was clear I needed to know a lot more to do quality improvement well,” she said.
Dr. Fang then enrolled in a general-medicine fellowship to gain formal research training. “Fellowship showed me how fun it was to ask questions and design studies to answer them, and how research could impact the care of many more patients than I ever could as a clinician,” she said.
The overall mission of her research program is now to equip clinicians and patients with the information they need to make good decisions when considering anticoagulants, Dr. Fang said. This includes how to balance the risk of thrombosis when off anticoagulants with the risk of bleeding while on them, as well as which patients should take which drugs.
Questioning work practices
The early studies of Marisha Burden, MD, MBA, FACP, SFHM (@marishaburden), professor of medicine and division head of hospital medicine at the University of Colorado School of Medicine in Aurora, Colo., delved into various aspects of work practices, including curbside consults, patient flow, a randomized controlled trial assessing the “bare below the elbows” policy’s impact on bacterial contamination of newly washed scrubs compared to white coats, and several investigations into gender inequities in leadership, speaking opportunities, and authorship.
Her research now centers around building and implementing evidence-based work-design practices. As her leadership roles expanded, she saw the profound impact of work design on outcomes such as the workforce, patients, and even organizational outcomes.
Researching health care disparities
Sagar Dugani, MD, PhD, MPH, FHM, initially focused on translational biology. However, providing care to patients from rural areas in the U.S. Midwest sparked an interest in health care disparities.
“Rural populations experience disparities in various care settings (e.g., hospital, outpatient),” said Dr. Dugani, an assistant professor of medicine at Mayo Clinic in Rochester, Minn., where he also serves as division of hospital internal medicine research chair and as director of the Hospital Experiences to Advance Goals and Outcomes Network (HEXAGON).
He now evaluates these disparities to design smarter interventions that work across care settings. “Our work leverages national, regional, and hospital datasets to understand how rurality (and related social determinants of health) affect outcomes.”
Practicing implementation science
During his residency, Dr. Bonafide became interested in issues surrounding patient safety and the implementation of improvement processes. “I felt there was a gap between understanding what we needed to measure to understand if these [processes] were really improving things for patients, doctors and nurses, and other staff and families,” he said.
Through a research fellowship and a course in implementation science, he learned how to design research studies to help bridge the gap between existing evidence and practice. Dr. Bonafide now works as an implementation scientist. “Implementation science is figuring out how to change the behavior of folks to align their practice with the best available evidence and also how to eliminate unnecessary practices that don’t benefit patients and families and may also potentially be harmful,” he said. He has studied alarm fatigue and strategies that help physicians decrease the amount of ineffective monitoring.
Improving patient care transitions
After developing an interest in research during medical school, Sunil Kripalani, MD, MSc, FACP, SFHM, decided early on to pursue an academic career. “Getting a foundation in research methods, including clinical trial design and survey research, was critical for me,” he said. Dr. Kripalani is a professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn., and director of Vanderbilt’s Center for Health Services Research and Center for Clinical Quality and Implementation Research.
Dr. Kripalani’s research primarily involves developing interventions to improve patient care transitions, mostly from hospital to home but also transitions involving emergency departments, intensive care units, and skilled nursing facilities. “Over time, I’ve shifted from testing interventions on a smaller scale to studying their implementation hospital-wide as we’ve learned what interventions are effective,” he said.
These hospitalist researchers said their clinical work and research work inform each other and add to the knowledge base. “My clinical work serves as a vital source of insights to inform workplace practices, and I believe we need more of this perspective in organizational decision-making processes,” Dr. Burden said.
Keeping focus on current work also helps balance the patient-care and research aspects. Dr. Kripalani found that spacing out his clinical weeks gave him large blocks of time when he could focus on research. “When I’m on service, I rely more on my research team to move things forward,” he said.
Synergizing or aligning clinical and research is ideal, the hospitalist researchers said. Dr. Fang feels very fortunate that her clinical and research interests are aligned. “From a practical standpoint, being a hospitalist allows me to focus on taking care of patients when I am on service, but then shift that attention to my research when I am off clinical service.”
Balancing clinical and research interests has been challenging, Dr. Burden said, because of her passion for all aspects of her work, including leadership, research, clinical practice, and education. “Because there is so much overlap in these areas, I’ve worked to integrate and synergize these efforts.”
Dr. Bonafide finds that time with residents gives him energy and ideas for new projects. “For me, the clinical and research work are nicely intertwined in a way that’s fun. It’s a wonderful balance.”
Getting the education
Hospitalists interested in research will require both a defined interest and formal training such as a master’s or PhD program, Dr. Fang said.
“Having a formal framework to design studies, analyze data, and interpret results is imperative to your own research program and to understanding others’ research,” Dr. Dugani said.
Completing a master’s degree or research fellowship is essential, with several outstanding programs around the country, Dr. Kripalani said. “These are good stepping stones to a career development award that will provide more time and support for mentored research.”
Hospitalists interested in research should be comfortable with writing frequent papers and grants, and comfortable with being rejected. “My grants, papers, proposals, etc., have been rejected,” Dr. Dugani said. “While painful, there was always something to learn, which helped [me] make better decisions.”
Collaborating and mentoring
Another common theme among hospitalist researchers is understanding the importance of collaboration and mentoring, both in the roles of mentor and mentee.
Dr. Burden said her educational efforts have evolved to focus on mentorship, particularly in the areas of helping mentees think about career growth and building the research pipeline. “It’s important to acknowledge that research is a collaborative effort,” she said. “The success of any research endeavor is a testament to the collective effort of a dedicated team.” She said she was grateful to have had an invaluable research partner throughout her career.
“If you’re just starting out, be sure you have great research mentors and enough time devoted to growing your research career,” Dr. Fang said. “It’s really hard to launch a successful research career when you have a lot of clinical responsibilities.”
Dr. Dugani advises hospitalists interested in research to reach out to colleagues and meet with senior researchers at conferences. “Don’t hesitate to explore, even if in a small way,” he said. “Every step you take will make the next one easier, and you will suddenly find yourself immersed in research and enjoying the process.”
Hospitalists with research interests should find a strong mentorship team, including mentors with expertise in decision making, their specific research-area interest, and scientific methodology, Dr. Bonafide said. For junior hospitalists, a sponsor could also help build connections to colleagues and opportunities. Choosing skilled research assistants is critical, he said, and collaborations with researchers with similar interests can be productive as well.
Over time, Dr. Fang has found mentoring to be one of the most fulfilling aspects of her research career. “I have learned so much from my mentees,” she said.
Taking the plunge
Dr. Burden said hospitalists considering entering into the research field should take the plunge.
“Research in hospital medicine can and does have a profound impact, both locally and beyond,” she said. “Witnessing the transformative potential of a study, even one undertaken with limited resources but fueled by dedication and perseverance, is incredibly empowering.”
Sue Coons is a medical writer in Chapel Hill, N.C.