Andrew D. Auerbach, MD, MPH

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

The past several years have seen a dramatic increase in the percentage of patients cared for by hospitalists, yet an emerging body of literature examining the association between care given by hospitalists and performance on a number of process measures has shown mixed results. Hospitalists do not appear to provide higher quality of care for pneumonia,1, 2 while results in heart failure are mixed.35 Each of these studies was conducted at a single site, and examined patient‐level effects. More recently, Vasilevskis et al6 assessed the association between the intensity of hospitalist use (measured as the percentage of patients admitted by hospitalists) and performance on process measures. In a cohort of 208 California hospitals, they found a significant improvement in performance on process measures in patients with acute myocardial infarction, heart failure, and pneumonia with increasing percentages of patients admitted by hospitalists.6

To date, no study has examined the association between the use of hospitalists and the publicly reported 30‐day mortality and readmission measures. Specifically, the Centers for Medicare and Medicaid Services (CMS) have developed and now publicly report risk‐standardized 30‐day mortality (RSMR) and readmission rates (RSRR) for Medicare patients hospitalized for 3 common and costly conditionsacute myocardial infarction (AMI), heart failure (HF), and pneumonia.7 Performance on these hospital‐based quality measures varies widely, and vary by hospital volume, ownership status, teaching status, and nurse staffing levels.813 However, even accounting for these characteristics leaves much of the variation in outcomes unexplained. We hypothesized that the presence of hospitalists within a hospital would be associated with higher performance on 30‐day mortality and 30‐day readmission measures for AMI, HF, and pneumonia. We further hypothesized that for hospitals using hospitalists, there would be a positive correlation between increasing percentage of patients admitted by hospitalists and performance on outcome measures. To test these hypotheses, we conducted a national survey of hospitalist leaders, linking data from survey responses to data on publicly reported outcome measures for AMI, HF, and pneumonia.

MATERIALS AND METHODS

RESULTS

DISCUSSION

In this national survey of hospitals, we did not find a significant association between the use of hospitalists and hospitals' performance on 30‐day mortality or readmissions measures for AMI, HF, or pneumonia. While there was a statistically lower 30‐day risk‐standardized readmission rate measure for the heart failure measure among hospitals that use hospitalists, the effect size was small. The survey response rate of 40% is comparable to other surveys of physicians and other healthcare personnel, however, there were no significant differences between responders and nonresponders, so the potential for response bias, while present, is small.

Contrary to the findings of a recent study,21 we did not find a higher readmission rate for any of the 3 conditions in hospitals with hospitalist programs. One advantage of our study is the use of more robust risk‐adjustment methods. Our study used NQF‐endorsed risk‐standardized measures of readmission, which capture readmissions to any hospital for common, high priority conditions where the impact of care coordination and discontinuity of care are paramount. The models use administrative claims data, but have been validated by medical record data. Another advantage is that our study focused on a time period when hospital readmissions were a standard quality benchmark and increasing priority for hospitals, hospitalists, and community‐based care delivery systems. While our study is not able to discern whether patients had primary care physicians or the reason for admission to a hospitalist's care, our data do suggest that hospitalists continue to care for a large percentage of hospitalized patients. Moreover, increasing the proportion of patients being admitted to hospitalists did not affect the risk for readmission, providing perhaps reassuring evidence (or lack of proof) for a direct association between use of hospitalist systems and higher risk for readmission.

While hospitals with hospitalists clearly did not have better mortality or readmission rates, an alternate viewpoint might hold that, despite concerns that hospitalists negatively impact care continuity, our data do not demonstrate an association between readmission rates and use of hospitalist services. It is possible that hospitals that have hospitalists may have more ability to invest in hospital‐based systems of care,22 an association which may incorporate any hospitalist effect, but our results were robust even after testing whether adjustment for hospital factors (such as profit status, size) affected our results.

It is also possible that secular trends in hospitals or hospitalist systems affected our results. A handful of single‐site studies carried out soon after the hospitalist model's earliest descriptions found a reduction in mortality and readmission rates with the implementation of a hospitalist program.2325 Alternatively, it may be that there has been a dilution of the effect of hospitalists as often occurs when any new innovation is spread from early adopter sites to routine practice. Consistent with other multicenter studies from recent eras,21, 26 our article's findings do not demonstrate an association between hospitalists and improved outcomes. Unlike other multicenter studies, we had access to disease‐specific risk‐adjustment methodologies, which may partially account for referral biases related to patient‐specific measures of acute or chronic illness severity.

Changes in the hospitalist effect over time have a number of explanations, some of which are relevant to our study. Recent evidence suggests that complex organizational characteristics, such as organizational values and goals, may contribute to performance on 30‐day mortality for AMI rather than specific processes and protocols27; intense focus on AMI as a quality improvement target is emblematic of a number of national initiatives that may have affected our results. Interestingly, hospitalist systems have changed over time as well. Early in the hospitalist movement, hospitalist systems were implemented largely at the behest of hospitals trying to reduce costs. In recent years, however, hospitalist systems are at least as frequently being implemented because outpatient‐based physicians or surgeons request hospitalists; hospitalists have been focused on care of uncoveredpatients, since the model's earliest description. In addition, some hospitals invest in hospitalist programs based on perceived ability of hospitalists to improve quality and achieve better patient outcomes in an era of payment increasingly being linked to quality of care metrics.

Our study has several limitations, six of which are noted here. First, while the hospitalist model has been widely embraced in the adult medicine field, in the absence of board certification, there is no gold standard definition of a hospitalist. It is therefore possible that some respondents may have represented groups that were identified incorrectly as hospitalists. Second, the data for the primary independent variable of interest was based upon self‐report and, therefore, subject to recall bias and potential misclassification of results. Respondents were not aware of our hypothesis, so the bias should not have been in one particular direction. Third, the data for the outcome variables are from 2008. They may, therefore, not reflect organizational enhancements related to use of hospitalists that are in process, and take years to yield downstream improvements on performance metrics. In addition, of the 429 hospitals that have hospitalist programs, 46 programs were initiated after 2008. While national performance on the 6 outcome variables has been relatively static over time,7 any significant change in hospital performance on these metrics since 2008 could suggest an overestimation or underestimation of the effect of hospitalist programs on patient outcomes. Fourth, we were not able to adjust for additional hospital or health system level characteristics that may be associated with hospitalist use or patient outcomes. Fifth, our regression models had significant collinearity, in that the presence of hospitalists was correlated with each of the covariates. However, this finding would indicate that our estimates may be overly conservative and could have contributed to our nonsignificant findings. Finally, outcomes for 2 of the 3 clinical conditions measured are ones for which hospitalists may less frequently provide care: acute myocardial infarction and heart failure. Outcome measures more relevant for hospitalists may be all‐condition, all‐cause, 30‐day mortality and readmission.

This work adds to the growing body of literature examining the impact of hospitalists on quality of care. To our knowledge, it is the first study to assess the association between hospitalist use and performance on outcome metrics at a national level. While our findings suggest that use of hospitalists alone may not lead to improved performance on outcome measures, a parallel body of research is emerging implicating broader system and organizational factors as key to high performance on outcome measures. It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes. Comparative effectiveness and implementation research that assess the contextual factors and interventions that lead to successful system improvement and better performance is increasingly needed. It is unlikely that a single factor, such as hospitalist use, will significantly impact 30‐day mortality or readmission and, therefore, multifactorial interventions are likely required. In addition, hospitalist use is a complex intervention as the structure, processes, training, experience, role in the hospital system, and other factors (including quality of hospitalists or the hospitalist program) vary across programs. Rather than focusing on the volume of care delivered by hospitalists, hospitals will likely need to support hospital medicine programs that have the time and expertise to devote to improving the quality and value of care delivered across the hospital system. This study highlights that interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

In order to improve resident supervision and timeliness of invasive bedside procedures such as paracentesis, thoracentesis, and lumbar puncture, some academic medical centers have implemented procedure services that focus on providing high‐quality procedural care.1, 2

Procedure services have the potential to affect patient satisfaction, a key indicator in quality of care measurment.3 Having senior physicians present increases patient comfort during outpatient case presentations4 and improves patient satisfaction with explanations of tests and medications.5 However, we had concerns that teaching during a procedure may heighten patient anxiety. Patients are reluctant to be the first patient of a resident or medical student for a procedure,68 and patients are more likely to refuse consent to have a resident perform complex procedures.8 In previous studies, patient satisfaction with gynecological exams and flexible sigmoidoscopy performed by residents was comparable to satisfaction with those performed by staff physicians,9, 10 though in the case of flexible sigmoidoscopy, procedure duration was slightly longer.10 Few, if any, data describe bedside teaching or patient impressions of physician communication during procedures.

We carried out a prospective study of patient perceptions of the University of California San Francisco (UCSF) Hospitalist Procedure Service (HPS). Our study had the primary goal of understanding how our modelwhich involves bedside procedural teaching and feedback in real time (eg, as the procedure is performed)is perceived by patients.

Patients and Methods

Results

Discussion

Even though novice interns performed procedures and simultaneous bedside teaching, patient satisfaction with a teaching procedure service was high, and reported complication rates were low. In addition, a majority of patients found discussions related to teaching activities reassuring and potentially important to their perception of care quality. Analogous studies examining patient satisfaction with endoscopic care found similar rates of patient satisfaction with endoscopists' bedside manner, technical skills, and pain control, but these studies included sedated patients.21 Our results are unique, as we evaluated awake patients with attention to perception of bedside teaching with novice interns.

Our findings offer an alternative strategy for bedside procedural teaching that employs transparency in the use of an expert and a trainee to introduce patients to bedside teaching by experts, which is not common at many academic medical centers.28 Patients may have been reassured by a clear explanation of the role of the service and the providers involved as well as an assurance of expertise and attention to patient comfort and safety. In addition to patient satisfaction, this model has the potential to impact both the safety of bedside procedures and housestaff education around procedure performance. For example, pneumothorax rates using our procedure service model are lower than those published (0% vs. 4% for ultrasound‐guided thoracentesis and 8.5% for thoracentesis by less experienced clinicians).29

Providers may be reluctant to teach at the bedside of awake patients for fear of heightening patient anxiety over trainee inexperience. In the 1960s similar fears were raised over the concern for patient anxiety with bedside rounding,30 but later studies revealed these concerns to be largely unfounded. Instead, bedside rounds have been shown to positively influence patients' feelings about their hospital experience and their relationships with their physicians compared with patients whose case presentations were made in a conference room.31, 32 Given the opportunity to comment on areas for improvement, patients in our study specifically elaborated regarding pain control, communication, and efficiency problems. Although 16% of patients did not find the communication of physicians reassuring, none of the negative comments reflected problems with bedside teaching, but rather concepts such as desiring a better explanation of steps throughout the procedure. Specifically, patients desire better communication for unanticipated pain.

There are several limitations to this study. Lack of patient satisfaction data from a control group of patients whose procedures were performed by attendings or housestaff alone limits our ability to draw conclusions about our satisfaction scores. The scarce applicable literature offers only imperfect comparison data. Because hospitalists were not blinded to the survey, attending behavior may have been subject to a Hawthorne effect.33 Consenting patients after the procedure could have provided hospitalists with an opportunity to exclude patients who appeared less satisfied with their procedure; however, attempts were made to prevent this behavior by requiring strict accounting of why a patient was not consented for the study. Use of alternative personnel for consent such as nurses was explored, but was found not to be feasible due to limited resources. These data are only applicable to English‐speaking patients who are literate and well enough to complete a survey. It is not clear whether the experience for other patients would reflect the same outcomes. It is plausible that non‐English‐speaking patients might have more concerns about incomprehensible conversations taking place during their procedure. Although the surveys were anonymous and patients were told that the proceduralists would not see individual responses, responses may have been biased out of patient concern that their response might affect their care. Hospitalists obtaining consent, however, were careful to stress anonymity and the distinction between the primary team and the procedure team.

Academic hospitals are struggling with providing quality procedural care while balancing housestaff education and experience.28 With hospitalists playing an increasingly prominent role in housestaff education and patient satisfaction initiatives, the supervision of housestaff by trained hospitalist faculty may help meet both aims in the performance of invasive bedside procedures, particularly at institutions where simulation training resources are limited. Although concern may exist for potential patient anxiety with bedside teaching, our data demonstrate high levels of patient satisfaction with a hospitalist procedure service despite novice procedure performers and an emphasis on teaching during the procedure.

In order to improve resident supervision and timeliness of invasive bedside procedures such as paracentesis, thoracentesis, and lumbar puncture, some academic medical centers have implemented procedure services that focus on providing high‐quality procedural care.1, 2

Procedure services have the potential to affect patient satisfaction, a key indicator in quality of care measurment.3 Having senior physicians present increases patient comfort during outpatient case presentations4 and improves patient satisfaction with explanations of tests and medications.5 However, we had concerns that teaching during a procedure may heighten patient anxiety. Patients are reluctant to be the first patient of a resident or medical student for a procedure,68 and patients are more likely to refuse consent to have a resident perform complex procedures.8 In previous studies, patient satisfaction with gynecological exams and flexible sigmoidoscopy performed by residents was comparable to satisfaction with those performed by staff physicians,9, 10 though in the case of flexible sigmoidoscopy, procedure duration was slightly longer.10 Few, if any, data describe bedside teaching or patient impressions of physician communication during procedures.

We carried out a prospective study of patient perceptions of the University of California San Francisco (UCSF) Hospitalist Procedure Service (HPS). Our study had the primary goal of understanding how our modelwhich involves bedside procedural teaching and feedback in real time (eg, as the procedure is performed)is perceived by patients.

Patients and Methods

Results

Discussion

Even though novice interns performed procedures and simultaneous bedside teaching, patient satisfaction with a teaching procedure service was high, and reported complication rates were low. In addition, a majority of patients found discussions related to teaching activities reassuring and potentially important to their perception of care quality. Analogous studies examining patient satisfaction with endoscopic care found similar rates of patient satisfaction with endoscopists' bedside manner, technical skills, and pain control, but these studies included sedated patients.21 Our results are unique, as we evaluated awake patients with attention to perception of bedside teaching with novice interns.

Our findings offer an alternative strategy for bedside procedural teaching that employs transparency in the use of an expert and a trainee to introduce patients to bedside teaching by experts, which is not common at many academic medical centers.28 Patients may have been reassured by a clear explanation of the role of the service and the providers involved as well as an assurance of expertise and attention to patient comfort and safety. In addition to patient satisfaction, this model has the potential to impact both the safety of bedside procedures and housestaff education around procedure performance. For example, pneumothorax rates using our procedure service model are lower than those published (0% vs. 4% for ultrasound‐guided thoracentesis and 8.5% for thoracentesis by less experienced clinicians).29

Providers may be reluctant to teach at the bedside of awake patients for fear of heightening patient anxiety over trainee inexperience. In the 1960s similar fears were raised over the concern for patient anxiety with bedside rounding,30 but later studies revealed these concerns to be largely unfounded. Instead, bedside rounds have been shown to positively influence patients' feelings about their hospital experience and their relationships with their physicians compared with patients whose case presentations were made in a conference room.31, 32 Given the opportunity to comment on areas for improvement, patients in our study specifically elaborated regarding pain control, communication, and efficiency problems. Although 16% of patients did not find the communication of physicians reassuring, none of the negative comments reflected problems with bedside teaching, but rather concepts such as desiring a better explanation of steps throughout the procedure. Specifically, patients desire better communication for unanticipated pain.

There are several limitations to this study. Lack of patient satisfaction data from a control group of patients whose procedures were performed by attendings or housestaff alone limits our ability to draw conclusions about our satisfaction scores. The scarce applicable literature offers only imperfect comparison data. Because hospitalists were not blinded to the survey, attending behavior may have been subject to a Hawthorne effect.33 Consenting patients after the procedure could have provided hospitalists with an opportunity to exclude patients who appeared less satisfied with their procedure; however, attempts were made to prevent this behavior by requiring strict accounting of why a patient was not consented for the study. Use of alternative personnel for consent such as nurses was explored, but was found not to be feasible due to limited resources. These data are only applicable to English‐speaking patients who are literate and well enough to complete a survey. It is not clear whether the experience for other patients would reflect the same outcomes. It is plausible that non‐English‐speaking patients might have more concerns about incomprehensible conversations taking place during their procedure. Although the surveys were anonymous and patients were told that the proceduralists would not see individual responses, responses may have been biased out of patient concern that their response might affect their care. Hospitalists obtaining consent, however, were careful to stress anonymity and the distinction between the primary team and the procedure team.

Academic hospitals are struggling with providing quality procedural care while balancing housestaff education and experience.28 With hospitalists playing an increasingly prominent role in housestaff education and patient satisfaction initiatives, the supervision of housestaff by trained hospitalist faculty may help meet both aims in the performance of invasive bedside procedures, particularly at institutions where simulation training resources are limited. Although concern may exist for potential patient anxiety with bedside teaching, our data demonstrate high levels of patient satisfaction with a hospitalist procedure service despite novice procedure performers and an emphasis on teaching during the procedure.

In order to improve resident supervision and timeliness of invasive bedside procedures such as paracentesis, thoracentesis, and lumbar puncture, some academic medical centers have implemented procedure services that focus on providing high‐quality procedural care.1, 2

Procedure services have the potential to affect patient satisfaction, a key indicator in quality of care measurment.3 Having senior physicians present increases patient comfort during outpatient case presentations4 and improves patient satisfaction with explanations of tests and medications.5 However, we had concerns that teaching during a procedure may heighten patient anxiety. Patients are reluctant to be the first patient of a resident or medical student for a procedure,68 and patients are more likely to refuse consent to have a resident perform complex procedures.8 In previous studies, patient satisfaction with gynecological exams and flexible sigmoidoscopy performed by residents was comparable to satisfaction with those performed by staff physicians,9, 10 though in the case of flexible sigmoidoscopy, procedure duration was slightly longer.10 Few, if any, data describe bedside teaching or patient impressions of physician communication during procedures.

We carried out a prospective study of patient perceptions of the University of California San Francisco (UCSF) Hospitalist Procedure Service (HPS). Our study had the primary goal of understanding how our modelwhich involves bedside procedural teaching and feedback in real time (eg, as the procedure is performed)is perceived by patients.

Patients and Methods

Results

Discussion

Even though novice interns performed procedures and simultaneous bedside teaching, patient satisfaction with a teaching procedure service was high, and reported complication rates were low. In addition, a majority of patients found discussions related to teaching activities reassuring and potentially important to their perception of care quality. Analogous studies examining patient satisfaction with endoscopic care found similar rates of patient satisfaction with endoscopists' bedside manner, technical skills, and pain control, but these studies included sedated patients.21 Our results are unique, as we evaluated awake patients with attention to perception of bedside teaching with novice interns.

Our findings offer an alternative strategy for bedside procedural teaching that employs transparency in the use of an expert and a trainee to introduce patients to bedside teaching by experts, which is not common at many academic medical centers.28 Patients may have been reassured by a clear explanation of the role of the service and the providers involved as well as an assurance of expertise and attention to patient comfort and safety. In addition to patient satisfaction, this model has the potential to impact both the safety of bedside procedures and housestaff education around procedure performance. For example, pneumothorax rates using our procedure service model are lower than those published (0% vs. 4% for ultrasound‐guided thoracentesis and 8.5% for thoracentesis by less experienced clinicians).29

Providers may be reluctant to teach at the bedside of awake patients for fear of heightening patient anxiety over trainee inexperience. In the 1960s similar fears were raised over the concern for patient anxiety with bedside rounding,30 but later studies revealed these concerns to be largely unfounded. Instead, bedside rounds have been shown to positively influence patients' feelings about their hospital experience and their relationships with their physicians compared with patients whose case presentations were made in a conference room.31, 32 Given the opportunity to comment on areas for improvement, patients in our study specifically elaborated regarding pain control, communication, and efficiency problems. Although 16% of patients did not find the communication of physicians reassuring, none of the negative comments reflected problems with bedside teaching, but rather concepts such as desiring a better explanation of steps throughout the procedure. Specifically, patients desire better communication for unanticipated pain.

There are several limitations to this study. Lack of patient satisfaction data from a control group of patients whose procedures were performed by attendings or housestaff alone limits our ability to draw conclusions about our satisfaction scores. The scarce applicable literature offers only imperfect comparison data. Because hospitalists were not blinded to the survey, attending behavior may have been subject to a Hawthorne effect.33 Consenting patients after the procedure could have provided hospitalists with an opportunity to exclude patients who appeared less satisfied with their procedure; however, attempts were made to prevent this behavior by requiring strict accounting of why a patient was not consented for the study. Use of alternative personnel for consent such as nurses was explored, but was found not to be feasible due to limited resources. These data are only applicable to English‐speaking patients who are literate and well enough to complete a survey. It is not clear whether the experience for other patients would reflect the same outcomes. It is plausible that non‐English‐speaking patients might have more concerns about incomprehensible conversations taking place during their procedure. Although the surveys were anonymous and patients were told that the proceduralists would not see individual responses, responses may have been biased out of patient concern that their response might affect their care. Hospitalists obtaining consent, however, were careful to stress anonymity and the distinction between the primary team and the procedure team.

Academic hospitals are struggling with providing quality procedural care while balancing housestaff education and experience.28 With hospitalists playing an increasingly prominent role in housestaff education and patient satisfaction initiatives, the supervision of housestaff by trained hospitalist faculty may help meet both aims in the performance of invasive bedside procedures, particularly at institutions where simulation training resources are limited. Although concern may exist for potential patient anxiety with bedside teaching, our data demonstrate high levels of patient satisfaction with a hospitalist procedure service despite novice procedure performers and an emphasis on teaching during the procedure.

Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.

Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.

Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.