SHM Student Scholar Project - Report Summary

Innovative Solutions for Supporting Academic Educational Missions in the Setting of Sustained and Disproportionate Clinical Growth: A Multi-site Qualitative Analysis of Academic Hospitalist Programs

Student Scholar: Vishruti Patel, MS4 at University of Colorado School of Medicine
Mentor: Dr. Marisha Burden, Division Head of Hospital Medicine, University of Colorado School of Medicine

As a SHM Student Scholar of the longitudinal grant, I have had the honor of working with Dr. Marisha Burden and the Division of Hospital Medicine Data Analysis team over the last year. I was introduced to methods and practices of qualitative research, learned about project management by working in a highly effective team, and had the opportunity to engage in a very rewarding project that will result in some very important and impactful findings.

Academic Medical Centers (AMCs) across the nation have continued to see significant clinical growth.¹ Hospitalist have been at the forefront of off-loading this clinical load. In fact, with the reduction in resident work hours in the early 2000s, there has been an increase in the number of hospitalists taking care of these patients.^2,3 While hospitalists are known for their efficient clinical management of a hospital’s patient census, they are also leaders in education and some of the finest teachers that residents and medical students encounter during their training. However, the unprecedented clinical growth has outpaced the growth of house-staff and medical student training programs and have led academic hospitalist teams to evolve their clinical and educational missions to these changing demands.⁴ Academic hospitalist groups across the nation have utilized various innovative strategies to restore the balance between their clinical and educational mission. However, the strategies utilized, and their impact is unknown. Thus, this project aimed to understand the following objectives:

Objective 1: Understand the clinical growth that academic hospitalist groups have faced and its impact on traditional educational teaching efforts.
Objective 2: Understand strategies utilized by academic hospitalist teams to manage a disproportionate growth in clinical activity compared to traditional teaching activities and the positive and negative impacts of these strategies.
Objective 3: Develop an understanding of best practices to support the clinical mission and educational missions.

In order to fulfill these study objectives, we conducted semi-structured interviews via virtual video call with hospitalist leaders (Division Head, Section Head) and educational leaders in hospital medicine at 17 AMCs. Our interview consisted of open-ended questions that focused on understanding the strategies used by the program to support and grow their educational mission, success and challenges with those strategies, models currently utilized to distribute teaching opportunities, and future implications and considerations. Interviewed were conducted until data saturation, recorded and transcribed. A code book was finalized after multiple revisions and discussion among the team. Interview transcripts were divided evenly among four teams and coded into Dedoose. We currently have a summary of all the coded transcripts and are now working on analyzing the data for patterns, themes, subthemes and co-coded groups.

Although the final results of the study are not available yet, the preliminary findings of some common themes we saw are summarized below according to the study objectives:

Table 1. Summary of Overarching Themes/Ideas from Preliminary Data

Objective 1: Understand the clinical growth that academic hospitalist groups have faced and its impact on traditional educational teaching efforts.

There is a historical perspective that the purpose of the hospitalist is primarily clinical, and that education/academic work is a second priority.
Various programs face disparities in funding where majority of support is for the clinical mission, and academic support suffers
Communication barriers exist among those in charge of the clinical mission and those in charge of academic missions. There is a need for an established understanding that as an AMC, teaching is not lower priority
Clinical demand has increased such that hospitalists are tired and may suffer from burnout. They feel that they are not investing in themselves or their career development in other academic venues because they are overworked with clinical duties.

Objective 2: Understand strategies utilized by academic hospitalist teams to manage a disproportionate growth in clinical activity compared to traditional teaching activities and the positive and negative impacts of these strategies.

Innovations in venues of teaching

Peer-to-Peer: expanding education to include opportunities that involve peer teaching/coaching. An example can be senior faculty providing feedback and coaching to improve teaching skills of junior faculty
Hospitalist expansion into educational leadership roles at the level of the residency program, clerkships, and sub-internships
Interdisciplinary collaboration: Expand to teach learners other than residents or medical students such as PA students, APPs, dental students, and pharmacy students. Collaborate with other services to have faculty teach (ex. Med/Peds residency).
Development of fellowships/tracks: some topics include informatics, high value medicine, patient safety, quality improvement, medical education.
Expand locations/footprints: student-run free clinics, procedure services, ICU, etc.

Distribution of teaching opportunities

Hospital medicine groups utilize different models to divide teaching opportunities: 1) merit based 2) equally/fixed 3) interest based
There are pros and cons of each model, though many seem to prefer to use the merit-based model due to the limitation in teaching opportunities and to give more opportunities to those that are interested and also to maintain a standard quality of teaching.
- Merit-based approach: Groups should have a transparent application process with steps in places to prevent senior faculty from monopolizing time on teaching services and offer opportunities to junior faculty and to ensure bias was minimized.
- Equally/fixed distribution model: all faculty receive an equal amount of teaching time. However, this meant that more skilled clinicians did not get more time in teaching even if desired, and faculty who were not interested in education were required to teach. Clear expectations must be set to ensure the quality of teaching.
- Interest based model: all who are interested received teaching time. This allows faculty who are interested to have these roles. However, if many faculty are interested in teaching time, the opportunities may still be limited for each attending.

Job sustainability

It is important to find ways to make sure hospitalists, especially those that may be waiting for teaching/academic opportunities, feel fulfilled in their roles with other non-traditional teaching opportunities or academic/scholarly engagement
With limited teaching service opportunity, divisions must find ways to make clinical only services attractive, so people favor it (adjusting number of shifts per month, patient caps, duration of shifts)
Want to prevent a “us” vs. “them” culture between teaching and non-teaching faculty

Role of leadership

Advocate for staff and address pushback from different stakeholders (such as hospital administration) that hinder the balance between the clinical and academic missions.
Play an integral role in forming collaborations with other leaders and interdisciplinary groups to expand teaching footprints and promote educational growth
May need to make challenging decisions/have challenging discussions when determining how to distribute teaching opportunities.
Develop clear and transparent framework to aid in decision-making about balancing teaching and clinical opportunities for faculty.

Our final results will develop an understanding of best practices to support the clinical mission and educational missions and will provide suggestions to academic hospitalist groups across the country on successfully managing their clinical and educational missions (Objective #3). A summary of interventions and strategies utilized by various academic hospitalist groups with their respective impact/outcome will serve as a guide for programs. An overarching theme that has emerged is the need for innovative solutions to create additional teaching/educational opportunities that go beyond the traditional model in order to sustain and support the educational mission. It comes down to redefining and growing the definition of what it means to be an academic hospitalist. Hopefully, the innovative ideas we learned about through our project will serve as a catalyst for the push for the need of innovation, collaboration, and scholarship in order to propagate educational growth.

Future research may further investigate the redefinition of what it means to be an academic hospitalist. In our project, various interviewees mentioned that hospitalists are largely exposed to the traditional teaching model of an attending on a resident or medical student team during their training and envision that as the identity of an academic hospitalist. Thus, it may be interesting to survey hospitalists across the country on their perspective about the academic hospitalist identity. Is there an overarching perspective? What may be biasing this view? How is this impacting innovation and growth of educational opportunities? Another area of future research may be to further investigate the financial and funding aspects/barriers to supporting educational growth opportunities.

Overall, my experience working with Dr. Burden has made me a curious questioner and analyzer for the need of system change. I have worked previously with Dr. Burden on a project focusing on COVID surge practices, and now this project focusing on balancing clinical and educational missions. I enjoy the scope of these projects focusing on the system level and working towards organized change and innovation. This opportunity has served as a rewarding experience helping me understand the intersection of leadership, scholarship and innovation in medicine. I know that going forward, I want to continue to learn from mentors like Dr. Burden and continue to work on similar scale projects and further develop my professional identity. Thank you SHM for giving me this opportunity!

References:

Enders, T, Conroy J. Advancing the Academic Health System for the Future. AAMC. 2014: 1-60.
Wachter RM, Goldman, L. Zero to 50,000–The 20thAnniversary of Hospitalist. N EnglJ Med.2016;375(11):1009-1011.
Sehgal NL, Shah HM, Parekh VI, Roy CL, Williams MV. Non–housestaff medicine services in academic centers: Models and challenges. J Hosp Med. 2008;3(3):247-255.
Johnston SC. Academic Medical Centers Too Large for Their OwnHealth.JAMA.2019;322(3):203-204.

Posted by Vishruti Patel on Sep 5, 2022 1:43 AM America/New_York