Micah Mann, MD

Hospitalists must create rapport and communicate large amounts of information in a short amount of time without having a prior relationship with the patient.¹ High-quality communication can improve satisfaction and compliance, while poor communication leaves patients ill prepared to transition back to the community.^2–10

Many medical schools use standardized patients (SPs) to both train and evaluate their students’ communication skills. To our knowledge, no published studies describe using SPs to assess or teach communication skills for hospitalists.

Our objective in this study was to use SPs to assess for deficits in our hospitalists’ communication skills and to determine whether feedback provided by SPs could improve hospitalist confidence in and performance of optimal communication behaviors.

METHODS

Setting and Participants

The study took place at the Morchand Center at Icahn School of Medicine at Mount Sinai, an SP center that trains medical students and residents. All 23 hospitalists had prior experience with SPs during their training and their main clinical duties were as attendings on teaching and non-teaching services at The Mount Sinai Hospital in New York City, a large academic center. Participation in the standardized encounters was required.

Scenario and Checklist Development

We developed 3 SP encounters around common hospitalist-patient interactions: daily rounding, discharge, and interacting with a difficult patient. In order to assess communication skills, we developed a checklist with 3 core domains: Courtesy and Respect, Listen, and Explain. Each domain corresponded to 1 of 3 questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that pertained to doctor’s communications skills: (1) How often did doctors treat you with courtesy and respect? (2) How often did doctors listen carefully to you? (3) How often did doctors explain things in a way you could understand? We then developed checklist items that corresponded to essential communication skills within each of the 3 domains. These communication skills were based on best practices and published literature.

Discharge Encounter (Table 2): Patient admitted the night before with abdominal pain by another hospitalist. The checklist was based on AIDET^®, an effective communication skills training protocol that our hospitalist group had been trained on.¹¹

Daily Rounding Encounter (Table 3): Patient being discharged after an admission for congestive heart failure. The checklist was developed from the Society of Hospital Medicine discharge toolkit.¹²

Difficult Patient Encounter (Table 4): A patient and his daughter who were unhappy because of a previously missed lung mass that was now found to be cancer. Our checklist was based on characteristics of therapeutic bedside manner.¹³

The checklist items were each scored using a 3-point scale of adequate, partial, or inadequate performance. A description of checklist items within each of the 3 domains is listed in Table 1. A postintervention survey was filled out by all hospitalists after the 3 encounters.

 

Simulated Encounters

All 3 encounters occurred on the same day and each one lasted 1 hour (20 minutes for the encounter, 10 minutes for a posttest survey, and 30 minutes of feedback from the SP). For each case, a task list was given to the hospitalist before walking into the room (Appendix 1). During the feedback session, the SP gave the hospitalist feedback using the case checklist items. They then watched a video of the encounter and the SP further emphasized areas for improvement.

SP Training

SP training consisted of three 3-hour training sessions, which included review of the case, script, guidance on scoring the checklist items, role plays with attending hospitalists, and feedback training. Each SP was assigned to only 1 case.

Seven of the 24 encounters for each SP were reviewed independently by 2 investigators who created a final score for each checklist item which was compared to the SP’s checklist item score. The kappa (k) statistic was used to evaluate inter-observer reliability using the SAS system software (SAS Institute Inc.).

Analysis

The percent of hospitalists who performed each checklist item adequately within in each of the 3 domains (Courtesy and Respect, Listen, and Explain) was calculated. To compare the 3 domains, t tests were used.

We calculated the percent that our hospitalist group received on the 3 HCAHPS doctor’s questions 1 year prior to our SP exercise and 1 year after the SP exercise.

RESULTS

Twenty-three hospitalists completed all 3 encounters. For the 3 domains (Courtesy and Respect, Listen, and Explain), hospitalists performed significantly better in the Listen domain compared to the other 2 domains, with a mean percent adequate score of 90.2 % (95% confidence interval [CI], 72.2%-100%; P < 0.05), and significantly worse in the Explain domain compared to the other 2 domains, with a mean percent adequate score of 65.0% (95% CI, 49.2%-83.6%; P < 0.05). The mean percent adequate score for the Courtesy and Respect domain was 81.6% (95% CI, 56%-100%). This was significantly higher than the Explain domain and significantly lower than the Listen domain.

Posttest survey results showed that hospitalists had an increased level of confidence in their bedside manner, patient satisfaction skills, and high-quality discharge discussion skills.

Inter-Rater Reliability

Inter-rater reliability for the discharge encounter, the daily rounding encounter, and the difficult patient encounter were 0.74 (95% CI, 0.64-0.84), 0.73 (95% CI, 0.63-0.82), and 0.73 (95% CI, 0.63-0.83), respectively.

HCAHPS

Four hundred sixteen HCAHPS surveys were returned in the year prior to our SP exercise, and the percent of patients who answered always to the questions on Courtesy and Respect, Listen, and Explain were 80.4%, 74.2 %, and 69.4 %, respectively. In the year after our SP exercise, 492 surveys were returned, and there was no significant change in HCAHP scores for the group (80.9% for Courtesy and Respect, 70.2% for the Listen question, and 70.5% for Explain).

DISCUSSION

We have shown that SPs can be used to assess deficits in hospitalist communication skills and provide feedback that can improve hospitalist confidence in performing optimal communication behaviors. We have also shown that hospitalists perceive the exercise as beneficial in improving their communication skills and perceive them as similar to their real patient encounters.

The Explain domain was significantly worse than the Courtesy and Respect and Listen domains for our hospitalists. Analysis of the checklist items within the Explain domain found that the items within this domain that were most problematic for hospitalists were summarizing information at the end of the encounter, using teach-back (a communication confirmation method where a healthcare provider asks a patient to repeat what was said to confirm understanding), encouraging additional questions by using open-ended statements (What questions do you have?) instead of close ended statements (Do you have any questions?), managing team and self-up, setting expectations on length of stay, and timing of tests. This correlated with our patient satisfaction HCAHPS data, which showed that patients consistently rated our hospitalists’ ability to explain things in a way they could understand lowest among the 3 questions. HCAHPS scores did not change after our SP exercise, and this lack of improvement may indicate that meaningful improvement in communication skills requires longitudinal interventions and real-time feedback rather than a single exercise, as was shown in a recent study looking at daily patient satisfaction score feedback given to internal medicine residents.¹⁴

Our study had several limitations. First, hospitalists knew they were being videotaped and observed, which may have altered their behaviors and may not reflect our hospitalists’ actual behaviors with patients. Furthermore, we did not examine whether the feedback given was incorporated into our hospitalists’ daily patient communications and whether this impacted our patients care other than examining HCAHPS scores.

 

CONCLUSION

SPs can be used to identify deficiencies in communication skills and provide specific guidance that improves hospitalist confidence in their communication skills.

Acknowledgment

This trial was funded by a grant from The Doctor’s Company Foundation.

Disclosure

None of the authors report any conflicts of interest.

 

Hospitalists must create rapport and communicate large amounts of information in a short amount of time without having a prior relationship with the patient.¹ High-quality communication can improve satisfaction and compliance, while poor communication leaves patients ill prepared to transition back to the community.^2–10

Many medical schools use standardized patients (SPs) to both train and evaluate their students’ communication skills. To our knowledge, no published studies describe using SPs to assess or teach communication skills for hospitalists.

Our objective in this study was to use SPs to assess for deficits in our hospitalists’ communication skills and to determine whether feedback provided by SPs could improve hospitalist confidence in and performance of optimal communication behaviors.

METHODS

Setting and Participants

The study took place at the Morchand Center at Icahn School of Medicine at Mount Sinai, an SP center that trains medical students and residents. All 23 hospitalists had prior experience with SPs during their training and their main clinical duties were as attendings on teaching and non-teaching services at The Mount Sinai Hospital in New York City, a large academic center. Participation in the standardized encounters was required.

Scenario and Checklist Development

We developed 3 SP encounters around common hospitalist-patient interactions: daily rounding, discharge, and interacting with a difficult patient. In order to assess communication skills, we developed a checklist with 3 core domains: Courtesy and Respect, Listen, and Explain. Each domain corresponded to 1 of 3 questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that pertained to doctor’s communications skills: (1) How often did doctors treat you with courtesy and respect? (2) How often did doctors listen carefully to you? (3) How often did doctors explain things in a way you could understand? We then developed checklist items that corresponded to essential communication skills within each of the 3 domains. These communication skills were based on best practices and published literature.

Discharge Encounter (Table 2): Patient admitted the night before with abdominal pain by another hospitalist. The checklist was based on AIDET^®, an effective communication skills training protocol that our hospitalist group had been trained on.¹¹

Daily Rounding Encounter (Table 3): Patient being discharged after an admission for congestive heart failure. The checklist was developed from the Society of Hospital Medicine discharge toolkit.¹²

Difficult Patient Encounter (Table 4): A patient and his daughter who were unhappy because of a previously missed lung mass that was now found to be cancer. Our checklist was based on characteristics of therapeutic bedside manner.¹³

The checklist items were each scored using a 3-point scale of adequate, partial, or inadequate performance. A description of checklist items within each of the 3 domains is listed in Table 1. A postintervention survey was filled out by all hospitalists after the 3 encounters.

 

Simulated Encounters

All 3 encounters occurred on the same day and each one lasted 1 hour (20 minutes for the encounter, 10 minutes for a posttest survey, and 30 minutes of feedback from the SP). For each case, a task list was given to the hospitalist before walking into the room (Appendix 1). During the feedback session, the SP gave the hospitalist feedback using the case checklist items. They then watched a video of the encounter and the SP further emphasized areas for improvement.

SP Training

SP training consisted of three 3-hour training sessions, which included review of the case, script, guidance on scoring the checklist items, role plays with attending hospitalists, and feedback training. Each SP was assigned to only 1 case.

Seven of the 24 encounters for each SP were reviewed independently by 2 investigators who created a final score for each checklist item which was compared to the SP’s checklist item score. The kappa (k) statistic was used to evaluate inter-observer reliability using the SAS system software (SAS Institute Inc.).

Analysis

The percent of hospitalists who performed each checklist item adequately within in each of the 3 domains (Courtesy and Respect, Listen, and Explain) was calculated. To compare the 3 domains, t tests were used.

We calculated the percent that our hospitalist group received on the 3 HCAHPS doctor’s questions 1 year prior to our SP exercise and 1 year after the SP exercise.

RESULTS

Twenty-three hospitalists completed all 3 encounters. For the 3 domains (Courtesy and Respect, Listen, and Explain), hospitalists performed significantly better in the Listen domain compared to the other 2 domains, with a mean percent adequate score of 90.2 % (95% confidence interval [CI], 72.2%-100%; P < 0.05), and significantly worse in the Explain domain compared to the other 2 domains, with a mean percent adequate score of 65.0% (95% CI, 49.2%-83.6%; P < 0.05). The mean percent adequate score for the Courtesy and Respect domain was 81.6% (95% CI, 56%-100%). This was significantly higher than the Explain domain and significantly lower than the Listen domain.

Posttest survey results showed that hospitalists had an increased level of confidence in their bedside manner, patient satisfaction skills, and high-quality discharge discussion skills.

Inter-Rater Reliability

Inter-rater reliability for the discharge encounter, the daily rounding encounter, and the difficult patient encounter were 0.74 (95% CI, 0.64-0.84), 0.73 (95% CI, 0.63-0.82), and 0.73 (95% CI, 0.63-0.83), respectively.

HCAHPS

Four hundred sixteen HCAHPS surveys were returned in the year prior to our SP exercise, and the percent of patients who answered always to the questions on Courtesy and Respect, Listen, and Explain were 80.4%, 74.2 %, and 69.4 %, respectively. In the year after our SP exercise, 492 surveys were returned, and there was no significant change in HCAHP scores for the group (80.9% for Courtesy and Respect, 70.2% for the Listen question, and 70.5% for Explain).

DISCUSSION

We have shown that SPs can be used to assess deficits in hospitalist communication skills and provide feedback that can improve hospitalist confidence in performing optimal communication behaviors. We have also shown that hospitalists perceive the exercise as beneficial in improving their communication skills and perceive them as similar to their real patient encounters.

The Explain domain was significantly worse than the Courtesy and Respect and Listen domains for our hospitalists. Analysis of the checklist items within the Explain domain found that the items within this domain that were most problematic for hospitalists were summarizing information at the end of the encounter, using teach-back (a communication confirmation method where a healthcare provider asks a patient to repeat what was said to confirm understanding), encouraging additional questions by using open-ended statements (What questions do you have?) instead of close ended statements (Do you have any questions?), managing team and self-up, setting expectations on length of stay, and timing of tests. This correlated with our patient satisfaction HCAHPS data, which showed that patients consistently rated our hospitalists’ ability to explain things in a way they could understand lowest among the 3 questions. HCAHPS scores did not change after our SP exercise, and this lack of improvement may indicate that meaningful improvement in communication skills requires longitudinal interventions and real-time feedback rather than a single exercise, as was shown in a recent study looking at daily patient satisfaction score feedback given to internal medicine residents.¹⁴

Our study had several limitations. First, hospitalists knew they were being videotaped and observed, which may have altered their behaviors and may not reflect our hospitalists’ actual behaviors with patients. Furthermore, we did not examine whether the feedback given was incorporated into our hospitalists’ daily patient communications and whether this impacted our patients care other than examining HCAHPS scores.

 

CONCLUSION

SPs can be used to identify deficiencies in communication skills and provide specific guidance that improves hospitalist confidence in their communication skills.

Acknowledgment

This trial was funded by a grant from The Doctor’s Company Foundation.

Disclosure

None of the authors report any conflicts of interest.

 

Hospitalists must create rapport and communicate large amounts of information in a short amount of time without having a prior relationship with the patient.¹ High-quality communication can improve satisfaction and compliance, while poor communication leaves patients ill prepared to transition back to the community.^2–10

Many medical schools use standardized patients (SPs) to both train and evaluate their students’ communication skills. To our knowledge, no published studies describe using SPs to assess or teach communication skills for hospitalists.

Our objective in this study was to use SPs to assess for deficits in our hospitalists’ communication skills and to determine whether feedback provided by SPs could improve hospitalist confidence in and performance of optimal communication behaviors.

METHODS

Setting and Participants

The study took place at the Morchand Center at Icahn School of Medicine at Mount Sinai, an SP center that trains medical students and residents. All 23 hospitalists had prior experience with SPs during their training and their main clinical duties were as attendings on teaching and non-teaching services at The Mount Sinai Hospital in New York City, a large academic center. Participation in the standardized encounters was required.

Scenario and Checklist Development

We developed 3 SP encounters around common hospitalist-patient interactions: daily rounding, discharge, and interacting with a difficult patient. In order to assess communication skills, we developed a checklist with 3 core domains: Courtesy and Respect, Listen, and Explain. Each domain corresponded to 1 of 3 questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that pertained to doctor’s communications skills: (1) How often did doctors treat you with courtesy and respect? (2) How often did doctors listen carefully to you? (3) How often did doctors explain things in a way you could understand? We then developed checklist items that corresponded to essential communication skills within each of the 3 domains. These communication skills were based on best practices and published literature.

Discharge Encounter (Table 2): Patient admitted the night before with abdominal pain by another hospitalist. The checklist was based on AIDET^®, an effective communication skills training protocol that our hospitalist group had been trained on.¹¹

Daily Rounding Encounter (Table 3): Patient being discharged after an admission for congestive heart failure. The checklist was developed from the Society of Hospital Medicine discharge toolkit.¹²

Difficult Patient Encounter (Table 4): A patient and his daughter who were unhappy because of a previously missed lung mass that was now found to be cancer. Our checklist was based on characteristics of therapeutic bedside manner.¹³

The checklist items were each scored using a 3-point scale of adequate, partial, or inadequate performance. A description of checklist items within each of the 3 domains is listed in Table 1. A postintervention survey was filled out by all hospitalists after the 3 encounters.

 

Simulated Encounters

All 3 encounters occurred on the same day and each one lasted 1 hour (20 minutes for the encounter, 10 minutes for a posttest survey, and 30 minutes of feedback from the SP). For each case, a task list was given to the hospitalist before walking into the room (Appendix 1). During the feedback session, the SP gave the hospitalist feedback using the case checklist items. They then watched a video of the encounter and the SP further emphasized areas for improvement.

SP Training

SP training consisted of three 3-hour training sessions, which included review of the case, script, guidance on scoring the checklist items, role plays with attending hospitalists, and feedback training. Each SP was assigned to only 1 case.

Seven of the 24 encounters for each SP were reviewed independently by 2 investigators who created a final score for each checklist item which was compared to the SP’s checklist item score. The kappa (k) statistic was used to evaluate inter-observer reliability using the SAS system software (SAS Institute Inc.).

Analysis

The percent of hospitalists who performed each checklist item adequately within in each of the 3 domains (Courtesy and Respect, Listen, and Explain) was calculated. To compare the 3 domains, t tests were used.

We calculated the percent that our hospitalist group received on the 3 HCAHPS doctor’s questions 1 year prior to our SP exercise and 1 year after the SP exercise.

RESULTS

Twenty-three hospitalists completed all 3 encounters. For the 3 domains (Courtesy and Respect, Listen, and Explain), hospitalists performed significantly better in the Listen domain compared to the other 2 domains, with a mean percent adequate score of 90.2 % (95% confidence interval [CI], 72.2%-100%; P < 0.05), and significantly worse in the Explain domain compared to the other 2 domains, with a mean percent adequate score of 65.0% (95% CI, 49.2%-83.6%; P < 0.05). The mean percent adequate score for the Courtesy and Respect domain was 81.6% (95% CI, 56%-100%). This was significantly higher than the Explain domain and significantly lower than the Listen domain.

Posttest survey results showed that hospitalists had an increased level of confidence in their bedside manner, patient satisfaction skills, and high-quality discharge discussion skills.

Inter-Rater Reliability

Inter-rater reliability for the discharge encounter, the daily rounding encounter, and the difficult patient encounter were 0.74 (95% CI, 0.64-0.84), 0.73 (95% CI, 0.63-0.82), and 0.73 (95% CI, 0.63-0.83), respectively.

HCAHPS

Four hundred sixteen HCAHPS surveys were returned in the year prior to our SP exercise, and the percent of patients who answered always to the questions on Courtesy and Respect, Listen, and Explain were 80.4%, 74.2 %, and 69.4 %, respectively. In the year after our SP exercise, 492 surveys were returned, and there was no significant change in HCAHP scores for the group (80.9% for Courtesy and Respect, 70.2% for the Listen question, and 70.5% for Explain).

DISCUSSION

We have shown that SPs can be used to assess deficits in hospitalist communication skills and provide feedback that can improve hospitalist confidence in performing optimal communication behaviors. We have also shown that hospitalists perceive the exercise as beneficial in improving their communication skills and perceive them as similar to their real patient encounters.

The Explain domain was significantly worse than the Courtesy and Respect and Listen domains for our hospitalists. Analysis of the checklist items within the Explain domain found that the items within this domain that were most problematic for hospitalists were summarizing information at the end of the encounter, using teach-back (a communication confirmation method where a healthcare provider asks a patient to repeat what was said to confirm understanding), encouraging additional questions by using open-ended statements (What questions do you have?) instead of close ended statements (Do you have any questions?), managing team and self-up, setting expectations on length of stay, and timing of tests. This correlated with our patient satisfaction HCAHPS data, which showed that patients consistently rated our hospitalists’ ability to explain things in a way they could understand lowest among the 3 questions. HCAHPS scores did not change after our SP exercise, and this lack of improvement may indicate that meaningful improvement in communication skills requires longitudinal interventions and real-time feedback rather than a single exercise, as was shown in a recent study looking at daily patient satisfaction score feedback given to internal medicine residents.¹⁴

Our study had several limitations. First, hospitalists knew they were being videotaped and observed, which may have altered their behaviors and may not reflect our hospitalists’ actual behaviors with patients. Furthermore, we did not examine whether the feedback given was incorporated into our hospitalists’ daily patient communications and whether this impacted our patients care other than examining HCAHPS scores.

 

CONCLUSION

SPs can be used to identify deficiencies in communication skills and provide specific guidance that improves hospitalist confidence in their communication skills.

Acknowledgment

This trial was funded by a grant from The Doctor’s Company Foundation.

Disclosure

None of the authors report any conflicts of interest.

 

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

 

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

 

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.

Although the term “hospitalist” was coined in 1996 in a New England Journal of Medicine article, the field of HM grew organically from pressure to optimize hospital economics and improve efficiency in economically pressed healthcare markets.¹

Scholarship in HM has also grown and now includes regular publications of investigations exploring optimization of efficiency and quality, many with an emphasis on patient safety. In this way, HM is a unique field, with tools for approaching problems that aren’t commonly used in other branches of medicine.

In parallel to the emergence of HM as a field distinct from general internal medicine (IM), the HM fellowship is similar but distinct. Such fellowships serve multiple purposes.

HM fellowships can add clinical expertise and scholarship skills for a career in HM. While early HM research focused on proving the value of the hospitalist model, the field has expanded greatly for those interested in an academic career. The molding of a safer, more efficient hospital of the future depends on the creativity and scholarship of HM leaders. Further, experts suggest that with its unique emphasis on quality, safety, and efficiency, the field will be a key player in healthcare reform.² Its strength lies in traditional clinical research, as well as further adoption of lessons from other fields including industry, ethnography, and public health.³ As such, fellowships to train future leaders and researchers is essential.

SHM’s website (www.hospitalmedicine.org/fellowships) lists dozens of IM hospitalist fellowships, as well as programs in family practice, pediatrics, and psychiatry. These programs last from one to three years, accept from one to six fellows per year, and exist in locations throughout the U.S. and Canada.

An excellent description of the nature and scope of pediatric HM fellowships was published last year in the Journal of Hospital Medicine.⁴ Descriptions of IM and HM fellowships also have been published.^3,5

Hospitalist fellowships, like IM fellowships, aren’t credentialed by a governing body. In contrast to subspecialty fellowships, no separate specialty board exam is required for admittance to the field after completion of fellowship. HM positions do not require training after residency, and HM job opportunities continue to outpace the available workforce. This is the basis for the most important question confronting anyone considering such a fellowship: How is a fellowship of benefit to a career as a hospitalist?

Program Types

Ranji and colleagues wrote that the “goal of hospital medicine fellowship training is to produce clinicians who are trained explicitly in studying and optimizing medical care of the hospitalized patient and in disseminating that knowledge for the advancement of patient care.”³ A review of information available for the different programs reveals two distinct approaches to this goal, with much overlap but distinct emphases:

Clinical programs usually last one year with a majority of time spent filling clinical responsibilities. In addition to providing focused exposure to HM with an emphasis on the Core Competencies in Hospital Medicine as outlined by SHM, such a program generally expands a trainee’s clinical scope. Additional training in palliative care, the management of neurologic emergencies, and comanagement of surgical patients are likely to be a part of clinical practice but often are underemphasized during residency. Research expectations vary, but most clinical programs allot some time for quality-improvement (QI) projects.

Clinical fellowships also afford more leadership training than most jobs would offer in the period immediately following residency. It also offers the possibility of refining clinical skills and developing a clinical niche.

 

Academic programs last two years and are characterized by two to four months of clinical responsibility per year. They offer a formal teaching curriculum and provide dedicated training in research, health policy, or health economics.³ Research training varies from program to program. Most include basic biostatistics and research-method coursework at a minimum; others offer the option to pursue a graduate degree in clinical research or public health.

Academic programs also offer dedicated research mentorship.

Other Considerations

The value of an HM fellowship lies in career development. The decision to commit to a relatively low-paying fellowship can be a difficult one, especially given the debt burden most graduating residents bear and the abundance of high-paying HM jobs. It also is important for those interested in a career as an academic hospitalist to consider not only HM fellowships, but other programs as well, such as the Robert Wood Johnson Clinical Scholars Program (rwjcsp.unc.edu/about/index.html).

While all of the fellowship programs aren’t geared specifically toward the hospitalist, they often incorporate faculty with expertise that would benefit a future academic hospitalist. Of course, the best fit for an individual depends on their particular interests and needs.

Fellowship in HM can offer training in clinical skills, clinical research, teaching, and quality and patient safety. Anyone interested in an HM career should consider a fellowship an opportunity for career development in a young specialty entrenched in revolutionizing the care of hospitalized patients. Academic HM fellowships hold the promise of empowering tomorrow’s academic leaders with the tools to continue to move the field forward. TH

Dr. Mann is a fellow in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City. Dr. Markoff is associate division chief and fellowship director in the division of hospital medicine, Department of Medicine, at Mount Sinai School of Medicine in New York City.

References

1. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med. 2006;1(4):248-252.
2. Wachter RM. Keynote presentation. SHM national meeting. National Harbor, Md.: May 2010.
3. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med. 2006;119(1):72.e1-e7.
4. Freed GL, Dunham KM, Research advisory committee of the American Board of Pediatrics. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4:157-163.
5. Arora V, Fang MC, Kripalani S, Amin AN. Preparing for “diastole”: advanced training opportunities for academic hospitalists. J Hosp Med. 2006;1(6):368-377.