Leading an Academic Hospitalist Program: Challenges and Opportunities

1. Leading an Academic Hospitalist Program: Challenges and Opportunities Scott A. Flanders, M.D. Associate Professor of Medicine Director, Hospitalist Program Associate Division Chief, General Medicine University of Michigan

2. Overview State of the Field Challenges Clinical demands vs. Academic mission Sustainability / Promotion Opportunities Academic Hospitalist Taskforce ABIM / Residency re-design Research The future Divisions of Hospital Medicine or Not

3. Overview State of the Field Challenges Clinical demands vs. Academic mission Sustainability / Promotion Opportunities Academic Hospitalist Taskforce ABIM / Residency re-design Research The future Divisions of Hospital Medicine or Not

4. Hospitalists �Official� Definition �Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital care� -SHM Practical Definition �Are you a hospitalist?� Yes = hospitalist Future Definition ABIM added qualification?

5. SHM/NAIP Membership

6. Number of U.S. Physicians

7. AHA 2003 Survey 5000 U.S. Hospitals 1/3 have hospital medicine groups 2/3 have hospital medicine groups if >200 beds 3/4 have hospital medicine groups if >500 beds 100% of hospitals on US News and World Report 2006 Honor Roll of America�s Best Hospitals

8. Academic Hospitalists Major Teaching Hospitals (AHA Survey) 2/3 have hospitalist programs Average 17 hospitalists / program 27 Chiefs of GIM 25 have hospitalists Median Size:12 (range 1-50) Years on faculty: 4 (range 1-12) >80% planning for growth

9. Academic Hospitalists Hospitalist Roles Clinical Care Delivery Inpatient Medicine Wards / Obs units / ED? Consults / Surgical Co-management Palliative Care Clinics (pre-op, urgent care, post-discharge) QI / Patient Safety Teaching Administration (clinical, QI, teaching, programmatic) Research

10. Academic Hospitalists Hospitalist Roles: Chiefs of GIM Inpatient Wards 100% 70% are on non-resident services Other roles Education 89% Consultation 85% Hospital Committees 84% Research 54% Clinic precepting 27% Personal clinic 8%

11. Academic Hospitalists S

12. Academic Hospitalists S

13. Overview State of the Field Challenges Clinical demands vs. Academic mission Sustainability / Promotion Opportunities Academic Hospitalist Taskforce ABIM / Residency re-design Research The future Divisions of Hospital Medicine or Not

14. Challenges Clinical demands vs. Academic mission Many faculty hired solely for clinical needs Focus is on RVUs, #admits, LOS, costs, call nights Hospital pays for the program in many AMCs �Subsidized� faculty Surgical co-management Nights / weekends Non-resident services

15. U of M Hospitalist FTEs

16. Challenges Non-Resident Services in AMCs Most AMCs have these Shift Based Nights / Weekends High Volume Little �education� mission No research Perceptions: Third class academic citizens Beneath specialists and generalists with residents �4th year medicine residents� doing �intern work� �Pretendings�

17. Challenges Mentoring and Promotion Mentoring is critical for success Most hospitalists are junior faculty Most hospitalist program directors are too What is the career path? Few tenured �hospitalist researchers� Faculty who self identify as a hospitalist and started their careers as a hospitalist N=3? In U.S. Few hospitalist division chiefs

18. Challenges Academic Development Few training programs Few funding sources for �hospitalist research� QI / Safety Education Diseases not �owned� by a specialty; DVT, C-diff, CAP Compete with specialists for NIH funding Med schools undervalue QI / Education research Little time to work on any of this

19. Challenges Promotion Requires Scholarly Work Dissemination beyond institutional walls �Creative scholarly activity includes the generation and publication of new knowledge� ��as evidenced by publication in peer-reviewed journals, chapters in major textbooks, lectures at national meetings�.or some other mode of communicating results and ideas� � formal research is not required but is highly valued insofar as it contributes to external recognition� Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

20. Challenges Barriers to Success Scholarly activities not well supported By Depts, Divisions, Hospitals Academic GIM slow to embrace hospitalists Lack of leadership / guidance to support academic missions Hospitalist directors, division chiefs, chairs Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

21. Overview State of the Field Challenges Clinical demands vs. Academic mission Sustainability / Promotion Opportunities Academic Hospitalist Taskforce ABIM / Residency re-design Research The future Divisions of Hospital Medicine or Not

22. Opportunities Academic Hospitalist Working Groups ACGIM / SGIM Taskforce SHM Taskforce Involvement with APM, AAIM, APDIM ACGIM / SGIM / Hospitalist Leaders Summit 12/06 Joint ACGIM, SGIM, SHM Summit Planned June 2007

23. Opportunities ACGIM / SGIM Taskforce Recommendations Hospitalists need to be embraced Create Sustainable Jobs Provide resources to support academic pursuits Leadership to support / negotiate Build resources for mentorship Promotion should value education / QI work

24. Opportunities The Needs of a Successful Academic Program Great Faculty Could have done anything, but chose hospital medicine People you want to be with Program Director: One who has been around the block Leadership role in Division, Department, and Hospital Assistant Director for big / complex programs A �rain-maker� / �steward� (or several) for research Hired as a hospitalist Committed faculty within another division (HSRD) Fellowship training a �MUST�

25. Opportunities The Needs of a Successful Academic Program Human resources Supportive Chair, Residency Director, (and faculty) Division / Department Administrator Build support with the �C�s�: CMO, COO, CEO, CFO An administrative assistant (the true �director�) Financial resources Faculty development QI / QA Meeting presentations Research

26. Opportunities The Needs of a Successful Academic Program Vision To be indispensable To be the best To grow to be viewed as a successful division The tripartite mission Faculty meet their career goals Faculty stay Faculty are recruited away (but many stay!) Other programs are modeled after yours

27. Opportunities Resources are Key! Get leadership buy-in for the vision Division Chief, Chair, Hospital Sustainable / Academically viable jobs $$$$: Do not negotiate a �break-even� deal $ for QI $ for Admin $ for Research Cost-saving in long run Reputation, recruiting, quality

28. Opportunities Hospitalists will need to do the hard work Achieving Clinical Excellence Teaching Excellence Research

29. Opportunities Establishing Clinical Excellence Develop a clinical niche Give clinical lectures to faculty and trainees in other departments Grand rounds Visit neighboring / smaller institutions to speak Present a clinical update at a regional (ACP?) or national meeting Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

30. Opportunities Establishing Teaching Excellence Make teaching an active rather than passive process Get feedback, work to improve Curricular / Educational innovation Evaluate it! Create an �education portfolio�; document your work Pursue leadership roles in student / resident education Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

31. Opportunities Residency Redesign AAIM, ABIM, ACP Task Force 2 year core, then individualized pathways Hospital Medicine Path Enhanced ambulatory training �True� clinician-educator faculty models needed Training Support Recognition

32. Opportunities ABIM and Hospital Medicine Oct 2006 ABIM votes in favor of �Focused Recognition in Hospital Medicine� Requirements Board Certified in Internal Medicine A period of practice in the field Demonstration of competency in key areas Clinical (MI, CAP, GI Bleed, etc.) QI / Safety / System Re-design A secure exam Re-certify in Hospital Medicine

33. Opportunitites Establishing Administrative Excellence Director of Hospitalist Program But also assistant / associate director Develop and Evaluate a QI project DVT, Medication reconciliation, RRT, etc. Committee leadership / institutional innovation Network! SHM, SGIM, ACP, Listserves, etc. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

34. Opportunities Leadership Skills SHM Leadership course ACGIM Courses Local mentoring of hospitalist leaders Chief of GIM Other Division Chief Department Chair Chief of Staff, COO

37. Opportunities The Hard Part: Scholarly Work Write-up your clinical cases vignettes, case reports, clinical problem solving Systematic / Narrative review in your clinical niche Evaluate and disseminate your QI interventions Establish links with trained researchers GIM researchers, subspecialty, VA HSRD Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.

38. Hospital Medicine Research Critical to the future success of the field A requirement for a �specialty� Desperately needed Key areas to target include Nosocomial Infections Errors and safety issues Common diseases (CAP, etc.) Translating research into practice But how to do it?

39. Hospital Medicine Research Build research expertise Within your group Recruit a �rain-maker� On the job training By partnering with another division (Gen Med?) A research infrastructure is needed Get the whole group involved A few leaders Lots of participants Goal of at least two �scholarly works� / year Reach out to others Subspecialists Other institutions

40. HELPS Consortium Hospitalists as Emerging Leaders in Patient Safety A consortium of 9 healthcare institutions in Michigan Academic, Government, Urban, Rural, Teaching, Non-Teaching One hospitalist / One patient safety or QI officer Targeting few to affect many 9 hospitalist programs : >80,000 admits / year

41. HELPS Consortium: Targets Device-Related Infections Creating a Culture of Safety Perioperative Care Discontinuities in Inpatient Care ICU: Preventing Nosocomial Pneumonia and Improving Antibiotic Utilization End of Life Care Inpatient Geriatrics: Preventing Falls

42. HELPS Consortium Dissemination of Best Practices Presentation of successful and failed implementations Research staff to assist with analysis of new interventions; rapid cycle improvement Identify predictors of success and failure Is the �hospitalist angle� worth pursuing?

43. U of M: SHARP Program Specialist-Hospitalist Allied Research Program Pair specialists with hospitalists Specialists: content knowledge / credibility Hospitalists: systems knowledge / availability Targets: Blood culture contaminants (ID) Medication misadventures (Pharm, Geriatrics) Codes: Time to Rescue (Cardiology) Transfusion practices (Cardiology, Heme-Onc)

44. Overview State of the Field Challenges Clinical demands vs. Academic mission Sustainability / Promotion Opportunities Academic Hospitalist Taskforce ABIM / Residency re-design Research The future Divisions of Hospital Medicine or Not

45. Divisions of Hospital Medicine How many of these are there? UCSD, UCSF, U Mass, OSU, Northwestern Division vs. Section Is the Hospitalist Program Director on the same level as Chief of Endocrinology? Is there an outpatient counterpart? Heterogeneity of Institutions Community Hospital: non-teaching Major academic medical center

46. Divisions of Hospital Medicine There will be a spectrum of organizational structures What are existing organizational principles Research / Training Clinical Domain Size / Revenue Other Variables The need for programmatic autonomy Culture Leadership Certification? Need for training programs

47. Divisions of Hospital Medicine Separate division more likely if: No overlap / interaction with rest of GIM division GIM not at all involved with inpatient medicine Hospitalists > Non-hospitalists One group less research oriented than the other (or no research); or research occurs in �centers� Separate training programs Strong hospitalist leader

48. Divisions of Hospital Medicine Within another division (GIM, Pulm?) if: Division has strong research / training mission All other divisions emphasize research / teaching Good Inpt / Outpt relationships Share projects Share infrastructure GIM attends some on wards Hospitalists do urgent care? GIM Chief / Hospitalist Lead interact well All politics is local

49. Conclusions Hospital Medicine is a growth industry Challenges exist Put the �academic� back in academic hospitalists Opportunities Exist Need vision Need buy-in Need resources

50. Steps for PromotionClinician Educator / Administrator National Reputation Peer reviewed publications work best Professional societies Leadership, committee involvement, meetings Invited Presentations Invite a colleague as a �visiting professor� Editorial journal / grant review Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you. Despite these limitations, we believe our results are important. Our data imply that there may be a tension for general internists between the practice of inpatient and outpatient care. Fewer hospital duties may perhaps increase career satisfaction for some outpatient-oriented internists However, longitudinal studies of both outpatient-oriented and hospital-based internists will be needed to enrich our understanding in this area Thank you.