Andrew D Auerbach, MD, MPH

The early phase of the COVID-19 pandemic was an extraordinarily uncertain, yet innovative, time.¹ Few data describe site-level effects of the many adaptations made to deal with surging case numbers, but studies of larger hospital referral regions (HRR) provide important clues.

In this issue of the Journal of Hospital Medicine, Janke et al² describe how availability of hospital resources in a region relate to COVID-19 mortality between March and June 2020.The authors’ findings suggest that, at least for early periods of the pandemic, having more intensive care unit (ICU), hospital bed, or nursing capacity per COVID-19 case was associated with lower mortality, while physician availability was not. Moreover, months later there were no associations between service or physician availability and HRR COVID-19 mortality. The authors observed variations in mortality rates in places commonly thought to have been overwhelmed early in the pandemic (April 2020), as well as in cities (Boston, Philadelphia, Hartford, Detroit, and Camden, New Jersey) that had a less prominent place in the news at that time.

Larger hospitals tend to have the resources necessary to make wholesale changes when preparing for a pandemic wave. Thus, Janke et al’s results may not have fully captured the pandemic’s potential impact in settings with fewer resources or in smaller hospitals, which are currently being overwhelmed.³

The number of cases and hospitalizations in this third wave of COVID-19 continues to rise, and the strain on healthcare resources has been felt across entire regions, making the results of this study even more salient. Hospital outcomes for COVID-19 are sensitive to limitations in physical locations (number of beds, ICU capacity) and nursing capacity. Nurses more often are assigned specifically to a bed or unit, and the number of patients per nurse is limited by state or local statute. Innovations such as COVID-19 field hospitals or redeploying existing beds (eg, converting postanesthesia care units to ICUs) offset physically constrained resources.⁴ On the other hand, lower acuity in this phase of the pandemic (eg, fewer ICU admissions) and shorter lengths of stay may produce higher turnover, producing more workforce stress, regardless of bed availability.

Early work of our COVID-19 collaborative⁵ suggests that the focus on localizing patients to geographic units or teams has given way to strategies that utilize more flexible team and bed-finding approaches. Clinical care has evolved to focus on more aggressive discharge strategies, with remote monitoring and hospital-at-home capabilities. Overall, the pandemic is providing fodder for future studies examining interaction between case volumes, physician and nurse availability, and evolution in clinical care practices. Most critically, it provides an opportunity to study health system flexibility and robustness with a lens that incorporates a view of the hospital and its surroundings as tightly related parts of care delivery. Because if there is one thing the pandemic is teaching us, it is that, more than ever, no hospital can be an island unto itself, and each hospital is part of a larger ecosystem where rising tides are felt throughout.

The early phase of the COVID-19 pandemic was an extraordinarily uncertain, yet innovative, time.¹ Few data describe site-level effects of the many adaptations made to deal with surging case numbers, but studies of larger hospital referral regions (HRR) provide important clues.

In this issue of the Journal of Hospital Medicine, Janke et al² describe how availability of hospital resources in a region relate to COVID-19 mortality between March and June 2020.The authors’ findings suggest that, at least for early periods of the pandemic, having more intensive care unit (ICU), hospital bed, or nursing capacity per COVID-19 case was associated with lower mortality, while physician availability was not. Moreover, months later there were no associations between service or physician availability and HRR COVID-19 mortality. The authors observed variations in mortality rates in places commonly thought to have been overwhelmed early in the pandemic (April 2020), as well as in cities (Boston, Philadelphia, Hartford, Detroit, and Camden, New Jersey) that had a less prominent place in the news at that time.

Larger hospitals tend to have the resources necessary to make wholesale changes when preparing for a pandemic wave. Thus, Janke et al’s results may not have fully captured the pandemic’s potential impact in settings with fewer resources or in smaller hospitals, which are currently being overwhelmed.³

The number of cases and hospitalizations in this third wave of COVID-19 continues to rise, and the strain on healthcare resources has been felt across entire regions, making the results of this study even more salient. Hospital outcomes for COVID-19 are sensitive to limitations in physical locations (number of beds, ICU capacity) and nursing capacity. Nurses more often are assigned specifically to a bed or unit, and the number of patients per nurse is limited by state or local statute. Innovations such as COVID-19 field hospitals or redeploying existing beds (eg, converting postanesthesia care units to ICUs) offset physically constrained resources.⁴ On the other hand, lower acuity in this phase of the pandemic (eg, fewer ICU admissions) and shorter lengths of stay may produce higher turnover, producing more workforce stress, regardless of bed availability.

Early work of our COVID-19 collaborative⁵ suggests that the focus on localizing patients to geographic units or teams has given way to strategies that utilize more flexible team and bed-finding approaches. Clinical care has evolved to focus on more aggressive discharge strategies, with remote monitoring and hospital-at-home capabilities. Overall, the pandemic is providing fodder for future studies examining interaction between case volumes, physician and nurse availability, and evolution in clinical care practices. Most critically, it provides an opportunity to study health system flexibility and robustness with a lens that incorporates a view of the hospital and its surroundings as tightly related parts of care delivery. Because if there is one thing the pandemic is teaching us, it is that, more than ever, no hospital can be an island unto itself, and each hospital is part of a larger ecosystem where rising tides are felt throughout.

The early phase of the COVID-19 pandemic was an extraordinarily uncertain, yet innovative, time.¹ Few data describe site-level effects of the many adaptations made to deal with surging case numbers, but studies of larger hospital referral regions (HRR) provide important clues.

In this issue of the Journal of Hospital Medicine, Janke et al² describe how availability of hospital resources in a region relate to COVID-19 mortality between March and June 2020.The authors’ findings suggest that, at least for early periods of the pandemic, having more intensive care unit (ICU), hospital bed, or nursing capacity per COVID-19 case was associated with lower mortality, while physician availability was not. Moreover, months later there were no associations between service or physician availability and HRR COVID-19 mortality. The authors observed variations in mortality rates in places commonly thought to have been overwhelmed early in the pandemic (April 2020), as well as in cities (Boston, Philadelphia, Hartford, Detroit, and Camden, New Jersey) that had a less prominent place in the news at that time.

Larger hospitals tend to have the resources necessary to make wholesale changes when preparing for a pandemic wave. Thus, Janke et al’s results may not have fully captured the pandemic’s potential impact in settings with fewer resources or in smaller hospitals, which are currently being overwhelmed.³

The number of cases and hospitalizations in this third wave of COVID-19 continues to rise, and the strain on healthcare resources has been felt across entire regions, making the results of this study even more salient. Hospital outcomes for COVID-19 are sensitive to limitations in physical locations (number of beds, ICU capacity) and nursing capacity. Nurses more often are assigned specifically to a bed or unit, and the number of patients per nurse is limited by state or local statute. Innovations such as COVID-19 field hospitals or redeploying existing beds (eg, converting postanesthesia care units to ICUs) offset physically constrained resources.⁴ On the other hand, lower acuity in this phase of the pandemic (eg, fewer ICU admissions) and shorter lengths of stay may produce higher turnover, producing more workforce stress, regardless of bed availability.

Early work of our COVID-19 collaborative⁵ suggests that the focus on localizing patients to geographic units or teams has given way to strategies that utilize more flexible team and bed-finding approaches. Clinical care has evolved to focus on more aggressive discharge strategies, with remote monitoring and hospital-at-home capabilities. Overall, the pandemic is providing fodder for future studies examining interaction between case volumes, physician and nurse availability, and evolution in clinical care practices. Most critically, it provides an opportunity to study health system flexibility and robustness with a lens that incorporates a view of the hospital and its surroundings as tightly related parts of care delivery. Because if there is one thing the pandemic is teaching us, it is that, more than ever, no hospital can be an island unto itself, and each hospital is part of a larger ecosystem where rising tides are felt throughout.

In their report celebrating the increase in the number of hospitalists from a few hundred in the 1990s to more than 50,000 in 2016, Drs Robert Wachter and Lee Goldman also noted the stunted growth of productive hospital medicine research programs, which presents a challenge to academic credibility in hospital medicine.¹ Given the substantial increase in the number of hospitalists over the past two decades, we surveyed adult academic hospital medicine groups to quantify the number of hospitalist clinician investigators and identify gaps in resources for researchers. The number of clinician investigators supported at academic medical centers (AMCs) remains disturbingly low despite the rapid growth of our specialty. Some programs also reported a lack of access to fundamental research services. We report selected results from our survey and provide recommendations to support and facilitate the development of clinician investigators in hospital medicine.

We performed a survey of hospital medicine programs at AMCs in the United States through the Hospital Medicine Reengineering Network (HOMERuN), a hospital medicine research collaborative that facilitates and conducts multisite research studies.² The purpose of this survey was to obtain a profile of adult academic hospital medicine groups. Surveys were distributed via email to directors and/or senior leaders of each hospital medicine group between January and August 2019. In the survey, a clinician investigator was defined as “faculty whose primary nonclinical focus is scientific papers and grant writing.”

We received responses from 43 of the 86 invitees (50%), each of whom represented a unique hospital medicine group; 41 of the representatives responded to the questions concerning available research services. Collectively, these 43 programs represented 2,503 hospitalists. There were 79 clinician investigators reported among all surveyed hospital medicine groups (3.1% of all hospitalists). The median number of clinician investigators per hospital medicine group was 0 (range 0-12) (Appendix Figure 1), and 22 of 43 (51.2%) hospital medicine groups reported having no clinician investigators. Two of the hospital medicine groups, however, reported having 12 clinician investigators at their respective institutions, comprising nearly one third of the total number of clinician investigators reported in the survey.

Many of the programs reported lack of access to resources such as research assistants (56.1%) and dedicated research fellowships (53.7%) (Appendix Figure 2). A number of groups reported a need for more support for various junior faculty development activities, including research mentoring (53.5%), networking with other researchers (60.5%), and access to clinical data from multiple sites (62.8%).

One of the limitations of this survey was the manner in which the participating hospital medicine groups were chosen. Selection was based on groups affiliated with HOMERuN; among those chosen were highly visible US AMCs, including 70% of the top 20 AMCs based on National Institutes of Health (NIH) funding.³ Therefore, our results likely overestimate the research presence of hospital medicine across all AMCs in the United States.

Despite the substantial growth of hospital medicine over the past 2 decades, there has been no proportional increase in the number of hospitalist clinician investigators, with earlier surveys also demonstrating low numbers.^4,5 Along with the survey by Chopra and colleagues published in 2019,⁶ our survey provides an additional contemporary appraisal of research activities for adult academic hospital medicine groups. In the survey by Chopra et al, only 54% (15 of 28) of responding programs reported having any faculty with research as their major activity (ie, >50% effort), and 3% of total faculty reported having funding for >50% effort toward research.⁶ Our study expands upon these findings by providing more detailed data on the number of clinician investigators per hospital medicine group. Results of our survey showed a concentration of hospitalists within a small number of programs, which may have contributed to the observed lack of growth. We also expand on prior work by identifying a lack of resources and services to support hospitalist researchers.

The findings of our survey have important implications for the field of hospital medicine. Without a critical mass of hospitalist clinician investigators, the quality of research that addresses important questions in our field will suffer. It will also limit academic credibility of the field, as well as individual academic achievement; previous studies have consistently demonstrated that few hospitalists at AMCs achieve the rank of associate or full professor.^5-9

The results of our study additionally offer possible explanations for the dearth of clinician investigators in hospital medicine. The limited access to research resources and fellowship training identified in our survey are critical domains that must be addressed in order to develop successful academic hospital medicine programs.^4,6,8,10

Regarding dedicated hospital medicine research fellowships, there are only a handful across the country. The small number of existing research fellowships only have one or two fellows per year, and these positions often go unfilled because of a lack of applicants and lower salaries compared to full-time clinical positions.¹¹ The lack of applicants for adult hospital medicine fellowship positions is also integrally linked to board certification requirements. Unlike pediatric hospital medicine where additional fellowship training is required to become board-certified, no such fellowship is required in adult hospital medicine. In pediatrics, this requirement has led to a rapid increase in the number of fellowships with scholarly work requirements (more than 60 fellowships, plus additional programs in development) and greater standardization among training experiences.^12,13

The lack of fellowship applicants may also stem from the fact that many trainees are not aware of a potential career as a hospitalist clinician investigator due to limited exposure to this career at most AMCs. Our results revealed that nearly half of sites in our survey had zero clinician investigators, depriving trainees at these programs of role models and thus perpetuating a negative feedback loop. Lastly, although unfilled fellowship positions may indicate that demand is a larger problem than supply, it is also true that fellowship programs generate their own demand through recruitment efforts and the gradual establishment of a positive reputation.

Another potential explanation could relate to the development of hospital medicine in response to rising clinical demands at hospitals: compared with other medical specialties, AMCs may regard hospitalists as being clinicians first and academicians second.^1,7,10 Also, hospitalists may be perceived as being beholden to hospitals and less engaged with their surrounding communities than other general medicine fields. With a small footprint in health equity research, academic hospital medicine may be less of a draw to generalists interested in pursuing this area of research. Further, there are very few underrepresented in medicine (URiM) hospital medicine research faculty.⁵

Another challenge to the career development of hospitalist researchers is the lack of available funding for the type of research typically conducted by hospitalists (eg, rigorous quality improvement implementation and evaluation, optimizing best evidence-based care delivery models, evaluation of patient safety in the hospital setting). As hospitalists tend to be system-level thinkers, this lack of funding may steer potential researchers away from externally funded research careers and into hospital operations and quality improvement positions. Also, unlike other medical specialties, there is no dedicated NIH funding source for hospital medicine research (eg, cardiology and the National Heart, Lung, and Blood Institute), placing hospitalists at a disadvantage in seeking funding compared to subspecialists.

We recommend several approaches—ones that should be pursued simultaneously—to increase the number of clinician investigators in hospital medicine. First, hospital medicine groups and their respective divisions, departments, and hospitals should allocate funding to support research resources; this includes investing in research assistants, data analysts, statisticians, and administrative support. Through the funding of such research infrastructure programs, AMCs could incentivize hospitalists to research best approaches to improve the value of healthcare delivery, ultimately leading to cost savings.

With 60% of respondents identifying the need for improved access to data across multiple sites, our survey also emphasizes the requirement for further collaboration among hospital medicine groups. Such collaboration could lead to high-powered observational studies and the evaluation of interventions across multiple sites, thus improving the generalizability of study findings.

The Society of Hospital Medicine (SHM) and its research committee can continue to expand the research footprint of hospital medicine. To date, the committee has achieved this by highlighting hospitalist research activity at the SHM Annual Conference Scientific Abstract and Poster Competition and developing a visiting professorship exchange program. In addition to these efforts, SHM could foster collaboration and networking between institutions, as well as take advantage of the current political push for expanded Medicare access by lobbying for robust funding for the Agency for Healthcare Research and Quality, which could provide more opportunities for hospitalists to study the effects of healthcare policy reform on the delivery of inpatient care.

Another strategy to increase the number of hospitalist clinician investigators is to expand hospital medicine research fellowships and recruit trainees for these programs. Fellowships could be internally funded wherein a fellow’s clinical productivity is used to offset the costs associated with obtaining advanced degrees. As an incentive to encourage applicants to temporarily forego a full-time clinical salary during fellowship, hospital medicine groups could offer expanded moonlighting opportunities and contribute to repayment of medical school loans. Hospital medicine groups should also advocate for NIH-funded T32 or K12 training grants for hospital medicine. (There are, however, challenges with this approach because the number of T32 spots per NIH institute is usually fixed). The success of academic emergency medicine offers a precedent for such efforts: After the development of a K12 research training program in emergency medicine, the number of NIH-sponsored principal investigators in this specialty increased by 40% in 6 years.¹⁴ Additionally, now that fellowships are required for the pediatric hospital medicine clinician investigators, it would be revealing to track the growth of this workforce.^12,13

Structured and formalized mentorship is an essential part of the development of clinician investigators in hospital medicine.^4,7,8,10 One successful strategy for mentorship has been the partnering of hospital medicine groups with faculty of general internal medicine and other subspecialty divisions with robust research programs.^7,8,15 In addition to developing sustainable mentorship programs, hospital medicine researchers must increase their visibility to trainees. Therefore, it is essential that the majority of academic hospital medicine groups not only hire clinician investigators but also invest in their development, rather than rely on the few programs that have several such faculty members. With this strategy, we could dramatically increase the number of hospitalist clinician investigators from a diverse background of training institutions.

SHM could also play a greater role in organizing events for networking and mentoring for trainees and medical students interested in pursuing a career in hospital medicine research. It is also critically important that hospital medicine groups actively recruit, retain, and develop URiM hospital medicine research faculty in order to attract talented researchers and actively participate in the necessary effort to mitigate the inequities prevalent throughout our healthcare system.

Despite the growth of hospital medicine over the past decade, there remains a dearth of hospitalist clinician investigators at major AMCs in the United States. This may be due in part to lack of research resources and mentorship within hospital medicine groups. We believe that investment in these resources, expanded funding opportunities, mentorship development, research fellowship programs, and greater exposure of trainees to hospitalist researchers are solutions that should be strongly considered to develop hospitalist clinician investigators.

The authors thank HOMERuN executive committee members, including Grant Fletcher, MD, James Harrison, PhD, BSC, MPH, Peter K. Lindenauer, MD, Melissa Mattison, MD, David Meltzer, MD, PhD, Joshua Metlay, MD, PhD, Jennifer Myers, MD, Sumant Ranji, MD, Gregory Ruhnke, MD, MPH, Edmondo Robinson, MD, MBA, and Neil Sehgal, MPH PhD, for their assistance in developing the survey. They also thank Tiffany Lee, MA, for her project management assistance for HOMERuN.

In their report celebrating the increase in the number of hospitalists from a few hundred in the 1990s to more than 50,000 in 2016, Drs Robert Wachter and Lee Goldman also noted the stunted growth of productive hospital medicine research programs, which presents a challenge to academic credibility in hospital medicine.¹ Given the substantial increase in the number of hospitalists over the past two decades, we surveyed adult academic hospital medicine groups to quantify the number of hospitalist clinician investigators and identify gaps in resources for researchers. The number of clinician investigators supported at academic medical centers (AMCs) remains disturbingly low despite the rapid growth of our specialty. Some programs also reported a lack of access to fundamental research services. We report selected results from our survey and provide recommendations to support and facilitate the development of clinician investigators in hospital medicine.

We performed a survey of hospital medicine programs at AMCs in the United States through the Hospital Medicine Reengineering Network (HOMERuN), a hospital medicine research collaborative that facilitates and conducts multisite research studies.² The purpose of this survey was to obtain a profile of adult academic hospital medicine groups. Surveys were distributed via email to directors and/or senior leaders of each hospital medicine group between January and August 2019. In the survey, a clinician investigator was defined as “faculty whose primary nonclinical focus is scientific papers and grant writing.”

We received responses from 43 of the 86 invitees (50%), each of whom represented a unique hospital medicine group; 41 of the representatives responded to the questions concerning available research services. Collectively, these 43 programs represented 2,503 hospitalists. There were 79 clinician investigators reported among all surveyed hospital medicine groups (3.1% of all hospitalists). The median number of clinician investigators per hospital medicine group was 0 (range 0-12) (Appendix Figure 1), and 22 of 43 (51.2%) hospital medicine groups reported having no clinician investigators. Two of the hospital medicine groups, however, reported having 12 clinician investigators at their respective institutions, comprising nearly one third of the total number of clinician investigators reported in the survey.

Many of the programs reported lack of access to resources such as research assistants (56.1%) and dedicated research fellowships (53.7%) (Appendix Figure 2). A number of groups reported a need for more support for various junior faculty development activities, including research mentoring (53.5%), networking with other researchers (60.5%), and access to clinical data from multiple sites (62.8%).

One of the limitations of this survey was the manner in which the participating hospital medicine groups were chosen. Selection was based on groups affiliated with HOMERuN; among those chosen were highly visible US AMCs, including 70% of the top 20 AMCs based on National Institutes of Health (NIH) funding.³ Therefore, our results likely overestimate the research presence of hospital medicine across all AMCs in the United States.

Despite the substantial growth of hospital medicine over the past 2 decades, there has been no proportional increase in the number of hospitalist clinician investigators, with earlier surveys also demonstrating low numbers.^4,5 Along with the survey by Chopra and colleagues published in 2019,⁶ our survey provides an additional contemporary appraisal of research activities for adult academic hospital medicine groups. In the survey by Chopra et al, only 54% (15 of 28) of responding programs reported having any faculty with research as their major activity (ie, >50% effort), and 3% of total faculty reported having funding for >50% effort toward research.⁶ Our study expands upon these findings by providing more detailed data on the number of clinician investigators per hospital medicine group. Results of our survey showed a concentration of hospitalists within a small number of programs, which may have contributed to the observed lack of growth. We also expand on prior work by identifying a lack of resources and services to support hospitalist researchers.

The findings of our survey have important implications for the field of hospital medicine. Without a critical mass of hospitalist clinician investigators, the quality of research that addresses important questions in our field will suffer. It will also limit academic credibility of the field, as well as individual academic achievement; previous studies have consistently demonstrated that few hospitalists at AMCs achieve the rank of associate or full professor.^5-9

The results of our study additionally offer possible explanations for the dearth of clinician investigators in hospital medicine. The limited access to research resources and fellowship training identified in our survey are critical domains that must be addressed in order to develop successful academic hospital medicine programs.^4,6,8,10

Regarding dedicated hospital medicine research fellowships, there are only a handful across the country. The small number of existing research fellowships only have one or two fellows per year, and these positions often go unfilled because of a lack of applicants and lower salaries compared to full-time clinical positions.¹¹ The lack of applicants for adult hospital medicine fellowship positions is also integrally linked to board certification requirements. Unlike pediatric hospital medicine where additional fellowship training is required to become board-certified, no such fellowship is required in adult hospital medicine. In pediatrics, this requirement has led to a rapid increase in the number of fellowships with scholarly work requirements (more than 60 fellowships, plus additional programs in development) and greater standardization among training experiences.^12,13

The lack of fellowship applicants may also stem from the fact that many trainees are not aware of a potential career as a hospitalist clinician investigator due to limited exposure to this career at most AMCs. Our results revealed that nearly half of sites in our survey had zero clinician investigators, depriving trainees at these programs of role models and thus perpetuating a negative feedback loop. Lastly, although unfilled fellowship positions may indicate that demand is a larger problem than supply, it is also true that fellowship programs generate their own demand through recruitment efforts and the gradual establishment of a positive reputation.

Another potential explanation could relate to the development of hospital medicine in response to rising clinical demands at hospitals: compared with other medical specialties, AMCs may regard hospitalists as being clinicians first and academicians second.^1,7,10 Also, hospitalists may be perceived as being beholden to hospitals and less engaged with their surrounding communities than other general medicine fields. With a small footprint in health equity research, academic hospital medicine may be less of a draw to generalists interested in pursuing this area of research. Further, there are very few underrepresented in medicine (URiM) hospital medicine research faculty.⁵

Another challenge to the career development of hospitalist researchers is the lack of available funding for the type of research typically conducted by hospitalists (eg, rigorous quality improvement implementation and evaluation, optimizing best evidence-based care delivery models, evaluation of patient safety in the hospital setting). As hospitalists tend to be system-level thinkers, this lack of funding may steer potential researchers away from externally funded research careers and into hospital operations and quality improvement positions. Also, unlike other medical specialties, there is no dedicated NIH funding source for hospital medicine research (eg, cardiology and the National Heart, Lung, and Blood Institute), placing hospitalists at a disadvantage in seeking funding compared to subspecialists.

We recommend several approaches—ones that should be pursued simultaneously—to increase the number of clinician investigators in hospital medicine. First, hospital medicine groups and their respective divisions, departments, and hospitals should allocate funding to support research resources; this includes investing in research assistants, data analysts, statisticians, and administrative support. Through the funding of such research infrastructure programs, AMCs could incentivize hospitalists to research best approaches to improve the value of healthcare delivery, ultimately leading to cost savings.

With 60% of respondents identifying the need for improved access to data across multiple sites, our survey also emphasizes the requirement for further collaboration among hospital medicine groups. Such collaboration could lead to high-powered observational studies and the evaluation of interventions across multiple sites, thus improving the generalizability of study findings.

The Society of Hospital Medicine (SHM) and its research committee can continue to expand the research footprint of hospital medicine. To date, the committee has achieved this by highlighting hospitalist research activity at the SHM Annual Conference Scientific Abstract and Poster Competition and developing a visiting professorship exchange program. In addition to these efforts, SHM could foster collaboration and networking between institutions, as well as take advantage of the current political push for expanded Medicare access by lobbying for robust funding for the Agency for Healthcare Research and Quality, which could provide more opportunities for hospitalists to study the effects of healthcare policy reform on the delivery of inpatient care.

Another strategy to increase the number of hospitalist clinician investigators is to expand hospital medicine research fellowships and recruit trainees for these programs. Fellowships could be internally funded wherein a fellow’s clinical productivity is used to offset the costs associated with obtaining advanced degrees. As an incentive to encourage applicants to temporarily forego a full-time clinical salary during fellowship, hospital medicine groups could offer expanded moonlighting opportunities and contribute to repayment of medical school loans. Hospital medicine groups should also advocate for NIH-funded T32 or K12 training grants for hospital medicine. (There are, however, challenges with this approach because the number of T32 spots per NIH institute is usually fixed). The success of academic emergency medicine offers a precedent for such efforts: After the development of a K12 research training program in emergency medicine, the number of NIH-sponsored principal investigators in this specialty increased by 40% in 6 years.¹⁴ Additionally, now that fellowships are required for the pediatric hospital medicine clinician investigators, it would be revealing to track the growth of this workforce.^12,13

Structured and formalized mentorship is an essential part of the development of clinician investigators in hospital medicine.^4,7,8,10 One successful strategy for mentorship has been the partnering of hospital medicine groups with faculty of general internal medicine and other subspecialty divisions with robust research programs.^7,8,15 In addition to developing sustainable mentorship programs, hospital medicine researchers must increase their visibility to trainees. Therefore, it is essential that the majority of academic hospital medicine groups not only hire clinician investigators but also invest in their development, rather than rely on the few programs that have several such faculty members. With this strategy, we could dramatically increase the number of hospitalist clinician investigators from a diverse background of training institutions.

SHM could also play a greater role in organizing events for networking and mentoring for trainees and medical students interested in pursuing a career in hospital medicine research. It is also critically important that hospital medicine groups actively recruit, retain, and develop URiM hospital medicine research faculty in order to attract talented researchers and actively participate in the necessary effort to mitigate the inequities prevalent throughout our healthcare system.

Despite the growth of hospital medicine over the past decade, there remains a dearth of hospitalist clinician investigators at major AMCs in the United States. This may be due in part to lack of research resources and mentorship within hospital medicine groups. We believe that investment in these resources, expanded funding opportunities, mentorship development, research fellowship programs, and greater exposure of trainees to hospitalist researchers are solutions that should be strongly considered to develop hospitalist clinician investigators.

The authors thank HOMERuN executive committee members, including Grant Fletcher, MD, James Harrison, PhD, BSC, MPH, Peter K. Lindenauer, MD, Melissa Mattison, MD, David Meltzer, MD, PhD, Joshua Metlay, MD, PhD, Jennifer Myers, MD, Sumant Ranji, MD, Gregory Ruhnke, MD, MPH, Edmondo Robinson, MD, MBA, and Neil Sehgal, MPH PhD, for their assistance in developing the survey. They also thank Tiffany Lee, MA, for her project management assistance for HOMERuN.

In their report celebrating the increase in the number of hospitalists from a few hundred in the 1990s to more than 50,000 in 2016, Drs Robert Wachter and Lee Goldman also noted the stunted growth of productive hospital medicine research programs, which presents a challenge to academic credibility in hospital medicine.¹ Given the substantial increase in the number of hospitalists over the past two decades, we surveyed adult academic hospital medicine groups to quantify the number of hospitalist clinician investigators and identify gaps in resources for researchers. The number of clinician investigators supported at academic medical centers (AMCs) remains disturbingly low despite the rapid growth of our specialty. Some programs also reported a lack of access to fundamental research services. We report selected results from our survey and provide recommendations to support and facilitate the development of clinician investigators in hospital medicine.

We performed a survey of hospital medicine programs at AMCs in the United States through the Hospital Medicine Reengineering Network (HOMERuN), a hospital medicine research collaborative that facilitates and conducts multisite research studies.² The purpose of this survey was to obtain a profile of adult academic hospital medicine groups. Surveys were distributed via email to directors and/or senior leaders of each hospital medicine group between January and August 2019. In the survey, a clinician investigator was defined as “faculty whose primary nonclinical focus is scientific papers and grant writing.”

We received responses from 43 of the 86 invitees (50%), each of whom represented a unique hospital medicine group; 41 of the representatives responded to the questions concerning available research services. Collectively, these 43 programs represented 2,503 hospitalists. There were 79 clinician investigators reported among all surveyed hospital medicine groups (3.1% of all hospitalists). The median number of clinician investigators per hospital medicine group was 0 (range 0-12) (Appendix Figure 1), and 22 of 43 (51.2%) hospital medicine groups reported having no clinician investigators. Two of the hospital medicine groups, however, reported having 12 clinician investigators at their respective institutions, comprising nearly one third of the total number of clinician investigators reported in the survey.

Many of the programs reported lack of access to resources such as research assistants (56.1%) and dedicated research fellowships (53.7%) (Appendix Figure 2). A number of groups reported a need for more support for various junior faculty development activities, including research mentoring (53.5%), networking with other researchers (60.5%), and access to clinical data from multiple sites (62.8%).

One of the limitations of this survey was the manner in which the participating hospital medicine groups were chosen. Selection was based on groups affiliated with HOMERuN; among those chosen were highly visible US AMCs, including 70% of the top 20 AMCs based on National Institutes of Health (NIH) funding.³ Therefore, our results likely overestimate the research presence of hospital medicine across all AMCs in the United States.

Despite the substantial growth of hospital medicine over the past 2 decades, there has been no proportional increase in the number of hospitalist clinician investigators, with earlier surveys also demonstrating low numbers.^4,5 Along with the survey by Chopra and colleagues published in 2019,⁶ our survey provides an additional contemporary appraisal of research activities for adult academic hospital medicine groups. In the survey by Chopra et al, only 54% (15 of 28) of responding programs reported having any faculty with research as their major activity (ie, >50% effort), and 3% of total faculty reported having funding for >50% effort toward research.⁶ Our study expands upon these findings by providing more detailed data on the number of clinician investigators per hospital medicine group. Results of our survey showed a concentration of hospitalists within a small number of programs, which may have contributed to the observed lack of growth. We also expand on prior work by identifying a lack of resources and services to support hospitalist researchers.

The findings of our survey have important implications for the field of hospital medicine. Without a critical mass of hospitalist clinician investigators, the quality of research that addresses important questions in our field will suffer. It will also limit academic credibility of the field, as well as individual academic achievement; previous studies have consistently demonstrated that few hospitalists at AMCs achieve the rank of associate or full professor.^5-9

The results of our study additionally offer possible explanations for the dearth of clinician investigators in hospital medicine. The limited access to research resources and fellowship training identified in our survey are critical domains that must be addressed in order to develop successful academic hospital medicine programs.^4,6,8,10

Regarding dedicated hospital medicine research fellowships, there are only a handful across the country. The small number of existing research fellowships only have one or two fellows per year, and these positions often go unfilled because of a lack of applicants and lower salaries compared to full-time clinical positions.¹¹ The lack of applicants for adult hospital medicine fellowship positions is also integrally linked to board certification requirements. Unlike pediatric hospital medicine where additional fellowship training is required to become board-certified, no such fellowship is required in adult hospital medicine. In pediatrics, this requirement has led to a rapid increase in the number of fellowships with scholarly work requirements (more than 60 fellowships, plus additional programs in development) and greater standardization among training experiences.^12,13

The lack of fellowship applicants may also stem from the fact that many trainees are not aware of a potential career as a hospitalist clinician investigator due to limited exposure to this career at most AMCs. Our results revealed that nearly half of sites in our survey had zero clinician investigators, depriving trainees at these programs of role models and thus perpetuating a negative feedback loop. Lastly, although unfilled fellowship positions may indicate that demand is a larger problem than supply, it is also true that fellowship programs generate their own demand through recruitment efforts and the gradual establishment of a positive reputation.

Another potential explanation could relate to the development of hospital medicine in response to rising clinical demands at hospitals: compared with other medical specialties, AMCs may regard hospitalists as being clinicians first and academicians second.^1,7,10 Also, hospitalists may be perceived as being beholden to hospitals and less engaged with their surrounding communities than other general medicine fields. With a small footprint in health equity research, academic hospital medicine may be less of a draw to generalists interested in pursuing this area of research. Further, there are very few underrepresented in medicine (URiM) hospital medicine research faculty.⁵

Another challenge to the career development of hospitalist researchers is the lack of available funding for the type of research typically conducted by hospitalists (eg, rigorous quality improvement implementation and evaluation, optimizing best evidence-based care delivery models, evaluation of patient safety in the hospital setting). As hospitalists tend to be system-level thinkers, this lack of funding may steer potential researchers away from externally funded research careers and into hospital operations and quality improvement positions. Also, unlike other medical specialties, there is no dedicated NIH funding source for hospital medicine research (eg, cardiology and the National Heart, Lung, and Blood Institute), placing hospitalists at a disadvantage in seeking funding compared to subspecialists.

We recommend several approaches—ones that should be pursued simultaneously—to increase the number of clinician investigators in hospital medicine. First, hospital medicine groups and their respective divisions, departments, and hospitals should allocate funding to support research resources; this includes investing in research assistants, data analysts, statisticians, and administrative support. Through the funding of such research infrastructure programs, AMCs could incentivize hospitalists to research best approaches to improve the value of healthcare delivery, ultimately leading to cost savings.

With 60% of respondents identifying the need for improved access to data across multiple sites, our survey also emphasizes the requirement for further collaboration among hospital medicine groups. Such collaboration could lead to high-powered observational studies and the evaluation of interventions across multiple sites, thus improving the generalizability of study findings.

The Society of Hospital Medicine (SHM) and its research committee can continue to expand the research footprint of hospital medicine. To date, the committee has achieved this by highlighting hospitalist research activity at the SHM Annual Conference Scientific Abstract and Poster Competition and developing a visiting professorship exchange program. In addition to these efforts, SHM could foster collaboration and networking between institutions, as well as take advantage of the current political push for expanded Medicare access by lobbying for robust funding for the Agency for Healthcare Research and Quality, which could provide more opportunities for hospitalists to study the effects of healthcare policy reform on the delivery of inpatient care.

Another strategy to increase the number of hospitalist clinician investigators is to expand hospital medicine research fellowships and recruit trainees for these programs. Fellowships could be internally funded wherein a fellow’s clinical productivity is used to offset the costs associated with obtaining advanced degrees. As an incentive to encourage applicants to temporarily forego a full-time clinical salary during fellowship, hospital medicine groups could offer expanded moonlighting opportunities and contribute to repayment of medical school loans. Hospital medicine groups should also advocate for NIH-funded T32 or K12 training grants for hospital medicine. (There are, however, challenges with this approach because the number of T32 spots per NIH institute is usually fixed). The success of academic emergency medicine offers a precedent for such efforts: After the development of a K12 research training program in emergency medicine, the number of NIH-sponsored principal investigators in this specialty increased by 40% in 6 years.¹⁴ Additionally, now that fellowships are required for the pediatric hospital medicine clinician investigators, it would be revealing to track the growth of this workforce.^12,13

Structured and formalized mentorship is an essential part of the development of clinician investigators in hospital medicine.^4,7,8,10 One successful strategy for mentorship has been the partnering of hospital medicine groups with faculty of general internal medicine and other subspecialty divisions with robust research programs.^7,8,15 In addition to developing sustainable mentorship programs, hospital medicine researchers must increase their visibility to trainees. Therefore, it is essential that the majority of academic hospital medicine groups not only hire clinician investigators but also invest in their development, rather than rely on the few programs that have several such faculty members. With this strategy, we could dramatically increase the number of hospitalist clinician investigators from a diverse background of training institutions.

SHM could also play a greater role in organizing events for networking and mentoring for trainees and medical students interested in pursuing a career in hospital medicine research. It is also critically important that hospital medicine groups actively recruit, retain, and develop URiM hospital medicine research faculty in order to attract talented researchers and actively participate in the necessary effort to mitigate the inequities prevalent throughout our healthcare system.

Despite the growth of hospital medicine over the past decade, there remains a dearth of hospitalist clinician investigators at major AMCs in the United States. This may be due in part to lack of research resources and mentorship within hospital medicine groups. We believe that investment in these resources, expanded funding opportunities, mentorship development, research fellowship programs, and greater exposure of trainees to hospitalist researchers are solutions that should be strongly considered to develop hospitalist clinician investigators.

The authors thank HOMERuN executive committee members, including Grant Fletcher, MD, James Harrison, PhD, BSC, MPH, Peter K. Lindenauer, MD, Melissa Mattison, MD, David Meltzer, MD, PhD, Joshua Metlay, MD, PhD, Jennifer Myers, MD, Sumant Ranji, MD, Gregory Ruhnke, MD, MPH, Edmondo Robinson, MD, MBA, and Neil Sehgal, MPH PhD, for their assistance in developing the survey. They also thank Tiffany Lee, MA, for her project management assistance for HOMERuN.

Recognizing the increasingly important role of point-of-care ultrasound (POCUS) in advancing clinical care, the Society of Hospital Medicine (SHM) has published a valuable series of position statements to guide hospitalists and administrators on the safe and effective use of POCUS.¹ In this issue of the Journal of Hospital Medicine, Soni et al. present a series of consensus-based recommendations on ultrasound guidance for lumbar puncture (LP).² Among these are the recommendations that ultrasound “should be used” to map the lumbar spine and to select an appropriate puncture site to reduce insertion attempts, reduce needle redirections, and increase overall procedural success.

At first glance, the recommendations appear definitive. However, not immediately obvious is the authors’ clarification that “This position statement does not mandate that hospitalists use ultrasound guidance for LP, nor does it establish ultrasound guidance as the standard of care for LP.” Even with the authors’ caveat, this nuance may not be readily apparent to the readers who review only the executive summary of the guidelines or who omit the context provided in the background of the position statement.

The directive language of this position statement may be a result of an unmerited amplification. The SHM POCUS Task Force employed the Research and Development Appropriateness Method to quantify the degree of consensus and the strength of the recommendation assigned,³ reaching “very good” consensus for each of the recommendations espoused in its position statement. Procedurally, this implies that ≥80% of the 27 voting members rated each published recommendation statement as “appropriate”. Using wording assigned a priori by the committee to each level of consensus, appropriateness became magnified to the declaration “should be used”. In this manner, the strength of the recommendations in this position statement is not necessarily based on the experts’ convictions related to ultrasound-guided LP, nor the strength of the supporting evidence.

In the case of ultrasound-guided LP, we might choose different descriptors than “appropriate” or “should be used”. The evidence base for ultrasound guidance for LP, though growing, may be insufficient as a foundation to a position statement and is certainly insufficient to create a new standard of care for hospitalists. Although the SHM POCUS Task Force completed a thoughtful literature review, no systematic approach (eg, GRADE methodology⁴) was used to rate the quality of evidence. Furthermore, the literature reviewed was drawn predominantly from anesthesia and emergency medicine sources—not readily generalizable to the hospitalist. Notably, these studies examined all neuraxial procedures (most commonly epidural and spinal anesthesia), which employ different techniques and tools than LP and are performed by clinicians with vastly different procedural training backgrounds than most hospitalists. Altogether, this creates the potential for a gap between true evidence quality and the strength of recommendation.

At a high level, although the technique for ultrasound mapping of the lumbar spine may be similar, the use of ultrasound has been less well studied specifically for LP. When considering LP alone, the available literature is inadequate to recommend uniform ultrasound guidance. A 2018 meta-analysis by Gottlieb et al. included 12 studies focusing only on LP, totaling N = 957 patients.⁵ This showed some favorability of ultrasound guidance, with a success rate of 90% using ultrasound, 81.4% with a landmark-based approach, and an odds ratio of 2.22 favoring ultrasound guidance (95% CI: 1.03-4.77). Unfortunately, when focusing only on adult patients, the advantage of POCUS diminished, with 91.4% success in the ultrasound group, 87.7% success in the landmark group, and a nonsignificant odds ratio of 2.10 (95% CI: 0.66-7.44).

Unequivocally, POCUS has established itself as a transformative technology for the guidance of invasive bedside procedures, bringing increased procedural success, improved safety, and decreased complication rates.⁶ For some procedures, particularly central venous catheterization, ultrasound guidance is a clear standard of care.^7,8 For LP, the greatest benefit has been observed in patients with anticipated procedural challenges, most commonly obese patients in whom landmarks are not easily palpable.⁹ Moreover, the harms ultrasound seeks to prevent are substantially different. The primary risk of deferring ultrasound guidance for LP is most often a failed procedure, whereas for other common ultrasound-guided procedures, the harms may include significant vascular injury, pneumothorax, or bowel perforation. Differences in the relative harms make risk-benefit assessments harder to quantify and studies harder to carry out.

Sonographic guidance for LP has a role in clinical practice and should always be considered. However, at present, there exist no guidelines in any other specialty regarding the routine use of ultrasound-guided LP, including anesthesia, emergency medicine, neurology, or interventional radiology.^10-15 As a result, a conservative interpretation of the POCUS Task Force’s findings would be to consider the use of ultrasound guidance for LP in patients where landmark identification is particularly challenging, but not to consider it a standard requirement for accreditation, training, or practice as of yet. Saying “more studies are required” can be a cop-out in some cases, but in this situation, the old adage does seem to apply.

We have great respect for the work of the SHM POCUS Task Force in advancing the use of POCUS in hospital medicine. Though ultrasound is not currently mandated as a care standard for the performance of LP, we all can agree that POCUS does confer advantages for this procedure, particularly in a well-selected patient population. To continue to provide care of the highest quality, hospitalists must be encouraged to elevate their practice with POCUS and be supported with the equipment, training, credentialing, and quality assurance structures necessary to integrate bedside ultrasound safely and effectively into their diagnostic and procedural practice.

Disclosures

No conflicts of interest to disclose.

Funding

None.

Recognizing the increasingly important role of point-of-care ultrasound (POCUS) in advancing clinical care, the Society of Hospital Medicine (SHM) has published a valuable series of position statements to guide hospitalists and administrators on the safe and effective use of POCUS.¹ In this issue of the Journal of Hospital Medicine, Soni et al. present a series of consensus-based recommendations on ultrasound guidance for lumbar puncture (LP).² Among these are the recommendations that ultrasound “should be used” to map the lumbar spine and to select an appropriate puncture site to reduce insertion attempts, reduce needle redirections, and increase overall procedural success.

At first glance, the recommendations appear definitive. However, not immediately obvious is the authors’ clarification that “This position statement does not mandate that hospitalists use ultrasound guidance for LP, nor does it establish ultrasound guidance as the standard of care for LP.” Even with the authors’ caveat, this nuance may not be readily apparent to the readers who review only the executive summary of the guidelines or who omit the context provided in the background of the position statement.

The directive language of this position statement may be a result of an unmerited amplification. The SHM POCUS Task Force employed the Research and Development Appropriateness Method to quantify the degree of consensus and the strength of the recommendation assigned,³ reaching “very good” consensus for each of the recommendations espoused in its position statement. Procedurally, this implies that ≥80% of the 27 voting members rated each published recommendation statement as “appropriate”. Using wording assigned a priori by the committee to each level of consensus, appropriateness became magnified to the declaration “should be used”. In this manner, the strength of the recommendations in this position statement is not necessarily based on the experts’ convictions related to ultrasound-guided LP, nor the strength of the supporting evidence.

In the case of ultrasound-guided LP, we might choose different descriptors than “appropriate” or “should be used”. The evidence base for ultrasound guidance for LP, though growing, may be insufficient as a foundation to a position statement and is certainly insufficient to create a new standard of care for hospitalists. Although the SHM POCUS Task Force completed a thoughtful literature review, no systematic approach (eg, GRADE methodology⁴) was used to rate the quality of evidence. Furthermore, the literature reviewed was drawn predominantly from anesthesia and emergency medicine sources—not readily generalizable to the hospitalist. Notably, these studies examined all neuraxial procedures (most commonly epidural and spinal anesthesia), which employ different techniques and tools than LP and are performed by clinicians with vastly different procedural training backgrounds than most hospitalists. Altogether, this creates the potential for a gap between true evidence quality and the strength of recommendation.

At a high level, although the technique for ultrasound mapping of the lumbar spine may be similar, the use of ultrasound has been less well studied specifically for LP. When considering LP alone, the available literature is inadequate to recommend uniform ultrasound guidance. A 2018 meta-analysis by Gottlieb et al. included 12 studies focusing only on LP, totaling N = 957 patients.⁵ This showed some favorability of ultrasound guidance, with a success rate of 90% using ultrasound, 81.4% with a landmark-based approach, and an odds ratio of 2.22 favoring ultrasound guidance (95% CI: 1.03-4.77). Unfortunately, when focusing only on adult patients, the advantage of POCUS diminished, with 91.4% success in the ultrasound group, 87.7% success in the landmark group, and a nonsignificant odds ratio of 2.10 (95% CI: 0.66-7.44).

Unequivocally, POCUS has established itself as a transformative technology for the guidance of invasive bedside procedures, bringing increased procedural success, improved safety, and decreased complication rates.⁶ For some procedures, particularly central venous catheterization, ultrasound guidance is a clear standard of care.^7,8 For LP, the greatest benefit has been observed in patients with anticipated procedural challenges, most commonly obese patients in whom landmarks are not easily palpable.⁹ Moreover, the harms ultrasound seeks to prevent are substantially different. The primary risk of deferring ultrasound guidance for LP is most often a failed procedure, whereas for other common ultrasound-guided procedures, the harms may include significant vascular injury, pneumothorax, or bowel perforation. Differences in the relative harms make risk-benefit assessments harder to quantify and studies harder to carry out.

Sonographic guidance for LP has a role in clinical practice and should always be considered. However, at present, there exist no guidelines in any other specialty regarding the routine use of ultrasound-guided LP, including anesthesia, emergency medicine, neurology, or interventional radiology.^10-15 As a result, a conservative interpretation of the POCUS Task Force’s findings would be to consider the use of ultrasound guidance for LP in patients where landmark identification is particularly challenging, but not to consider it a standard requirement for accreditation, training, or practice as of yet. Saying “more studies are required” can be a cop-out in some cases, but in this situation, the old adage does seem to apply.

We have great respect for the work of the SHM POCUS Task Force in advancing the use of POCUS in hospital medicine. Though ultrasound is not currently mandated as a care standard for the performance of LP, we all can agree that POCUS does confer advantages for this procedure, particularly in a well-selected patient population. To continue to provide care of the highest quality, hospitalists must be encouraged to elevate their practice with POCUS and be supported with the equipment, training, credentialing, and quality assurance structures necessary to integrate bedside ultrasound safely and effectively into their diagnostic and procedural practice.

Disclosures

No conflicts of interest to disclose.

Funding

None.

Recognizing the increasingly important role of point-of-care ultrasound (POCUS) in advancing clinical care, the Society of Hospital Medicine (SHM) has published a valuable series of position statements to guide hospitalists and administrators on the safe and effective use of POCUS.¹ In this issue of the Journal of Hospital Medicine, Soni et al. present a series of consensus-based recommendations on ultrasound guidance for lumbar puncture (LP).² Among these are the recommendations that ultrasound “should be used” to map the lumbar spine and to select an appropriate puncture site to reduce insertion attempts, reduce needle redirections, and increase overall procedural success.

At first glance, the recommendations appear definitive. However, not immediately obvious is the authors’ clarification that “This position statement does not mandate that hospitalists use ultrasound guidance for LP, nor does it establish ultrasound guidance as the standard of care for LP.” Even with the authors’ caveat, this nuance may not be readily apparent to the readers who review only the executive summary of the guidelines or who omit the context provided in the background of the position statement.

The directive language of this position statement may be a result of an unmerited amplification. The SHM POCUS Task Force employed the Research and Development Appropriateness Method to quantify the degree of consensus and the strength of the recommendation assigned,³ reaching “very good” consensus for each of the recommendations espoused in its position statement. Procedurally, this implies that ≥80% of the 27 voting members rated each published recommendation statement as “appropriate”. Using wording assigned a priori by the committee to each level of consensus, appropriateness became magnified to the declaration “should be used”. In this manner, the strength of the recommendations in this position statement is not necessarily based on the experts’ convictions related to ultrasound-guided LP, nor the strength of the supporting evidence.

In the case of ultrasound-guided LP, we might choose different descriptors than “appropriate” or “should be used”. The evidence base for ultrasound guidance for LP, though growing, may be insufficient as a foundation to a position statement and is certainly insufficient to create a new standard of care for hospitalists. Although the SHM POCUS Task Force completed a thoughtful literature review, no systematic approach (eg, GRADE methodology⁴) was used to rate the quality of evidence. Furthermore, the literature reviewed was drawn predominantly from anesthesia and emergency medicine sources—not readily generalizable to the hospitalist. Notably, these studies examined all neuraxial procedures (most commonly epidural and spinal anesthesia), which employ different techniques and tools than LP and are performed by clinicians with vastly different procedural training backgrounds than most hospitalists. Altogether, this creates the potential for a gap between true evidence quality and the strength of recommendation.

At a high level, although the technique for ultrasound mapping of the lumbar spine may be similar, the use of ultrasound has been less well studied specifically for LP. When considering LP alone, the available literature is inadequate to recommend uniform ultrasound guidance. A 2018 meta-analysis by Gottlieb et al. included 12 studies focusing only on LP, totaling N = 957 patients.⁵ This showed some favorability of ultrasound guidance, with a success rate of 90% using ultrasound, 81.4% with a landmark-based approach, and an odds ratio of 2.22 favoring ultrasound guidance (95% CI: 1.03-4.77). Unfortunately, when focusing only on adult patients, the advantage of POCUS diminished, with 91.4% success in the ultrasound group, 87.7% success in the landmark group, and a nonsignificant odds ratio of 2.10 (95% CI: 0.66-7.44).

Unequivocally, POCUS has established itself as a transformative technology for the guidance of invasive bedside procedures, bringing increased procedural success, improved safety, and decreased complication rates.⁶ For some procedures, particularly central venous catheterization, ultrasound guidance is a clear standard of care.^7,8 For LP, the greatest benefit has been observed in patients with anticipated procedural challenges, most commonly obese patients in whom landmarks are not easily palpable.⁹ Moreover, the harms ultrasound seeks to prevent are substantially different. The primary risk of deferring ultrasound guidance for LP is most often a failed procedure, whereas for other common ultrasound-guided procedures, the harms may include significant vascular injury, pneumothorax, or bowel perforation. Differences in the relative harms make risk-benefit assessments harder to quantify and studies harder to carry out.

Sonographic guidance for LP has a role in clinical practice and should always be considered. However, at present, there exist no guidelines in any other specialty regarding the routine use of ultrasound-guided LP, including anesthesia, emergency medicine, neurology, or interventional radiology.^10-15 As a result, a conservative interpretation of the POCUS Task Force’s findings would be to consider the use of ultrasound guidance for LP in patients where landmark identification is particularly challenging, but not to consider it a standard requirement for accreditation, training, or practice as of yet. Saying “more studies are required” can be a cop-out in some cases, but in this situation, the old adage does seem to apply.

We have great respect for the work of the SHM POCUS Task Force in advancing the use of POCUS in hospital medicine. Though ultrasound is not currently mandated as a care standard for the performance of LP, we all can agree that POCUS does confer advantages for this procedure, particularly in a well-selected patient population. To continue to provide care of the highest quality, hospitalists must be encouraged to elevate their practice with POCUS and be supported with the equipment, training, credentialing, and quality assurance structures necessary to integrate bedside ultrasound safely and effectively into their diagnostic and procedural practice.

Disclosures

No conflicts of interest to disclose.

Funding

None.