Natalia Paciorkowski, MD, PhD

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.