Scott M. Wright, MD

Explosive growth in hospital medicine has led to hospitalists having the option to change jobs easily. Annual turnover for all physicians is 6.8%, whereas that of hospitalists exceeds 14.8%.[1] Losing a single physician has significant financial and operational implications, with estimates of $20,000 to $120,000 in recruiting costs, and up to $500,000 in lost revenue that may take years to recoup due to the time required for new physician assimilation.[2, 3] In 2006, the Society of Hospital Medicine (SHM) appointed a career task force to develop retention recommendations, 1 of which includes monitoring hospitalists' job satisfaction.[4]

Studies examining physician satisfaction have demonstrated that high physician job satisfaction is associated with lower physician turnover.[5] However, surveys of hospitalists, including SHM's Hospital Medicine Physician Worklife Survey (HMPWS), have reported high job satisfaction among hospitalists,[6, 7, 8, 9, 10] suggesting that high job satisfaction may not be enough to overcome forces that pull hospitalists toward other opportunities.

Morale, a more complex construct related to an individual's contentment and happiness, might provide insight into reducing hospitalist turnover. Morale has been defined as the emotional or mental condition with respect to cheerfulness, confidence, or zeal and is especially relevant in the face of opposition or hardship.[11] Job satisfaction is 1 element that contributes to morale, but alone does not equate morale.[12] Morale, more than satisfaction, relates to how people see themselves within the group and may be closely tied to the concept of esprit de corps. To illustrate, workers may feel satisfied with the content of their job, but frustration with the organization may result in low morale.[13] Efforts focused on assessing provider morale may provide deeper understanding of hospitalists' professional needs and garner insight for retention strategies.

The construct of hospitalist morale and its underlying drivers has not been explored in the literature. Using literature within and outside of healthcare,[1, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22] and our own prior work,[23] we sought to characterize elements that contribute to hospitalist morale and develop a metric to measure it. The HMPWS found that job satisfaction factors vary across hospitalist groups.[9] We suspected that the same would hold true for factors important to morale at the individual level. This study describes the development and validation of the Hospitalist Morale Index (HMI), and explores the relationship between morale and intent to leave due to unhappiness.

METHODS

RESULTS

Personal Morale Scores and Factor Scores

Personal morale scores were normally distributed (mean = 2.79; standard deviation [SD] = 0.58), ranging from 1.23 to 4.22, with a theoretical low of 0 and high of 5 (Figure 1). Mean personal morale scores across hospitalist groups ranged from 2.70 to 2.99 (P > 0.05). Personal morale scores, factor sores and item scores for NPs and PAs did not significantly differ from those of physicians (P > 0.05 for all analyses). Personal morale scores were lower for those in their first 3 years with their current group, compared to those with greater institutional longevity. For every categorical increase in a participant's response to seeing oneself as a career hospitalist, the personal morale score rose 0.23 points (P < 0.001).

Figure 1

Factor scores for material reward and mean item scores for professional growth were significantly different across the 5 hospitalist groups (P = 0.03 and P < 0.001, respectively). Community hospitalists had significantly higher factor scores, despite having similar importance scores, for material rewards than academic hospitalists (diff. = 0.44, P = 0.02). Academic hospitalists had significantly higher scores for professional growth (diff. = 0.94, P < 0.001) (Table 2). Professional growth had the highest importance score for academic hospitalists (mean = 0.87, SD = 0.18) and the lowest importance score for community hospitalists (mean = 0.65, SD = 0.24, P < 0.001).

Table 2.Personal Morale Scores, Factor Scores,* and Five Item Scores* by Hospitalist Groups

		Personal Morale Score	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Item 1	Item 2	Item 3	Item 4	Item 5
			Clinical	Workload	Leadership	Appreciation and Acknowledgement	Material Rewards	Family Time	Institutional Climate	Job Security	Autonomy	Professional Growth
NOTE: Abbreviations: SD, standard deviation.*Factor scores and item scores represent the combined product of importance and contentment.
All participants	Mean	2.79	2.54	2.78	3.18	2.58	2.48	3.05	2.67	2.92	3.00	2.76
	SD	0.58	0.63	0.70	0.95	0.86	0.85	1.15	0.97	1.11	1.10	1.21
Academic A	Mean	2.77	2.43	2.92	3.10	2.54	2.28	3.16	2.70	3.06	3.20	3.08
	SD	0.57	0.62	0.64	0.92	0.84	0.77	1.19	0.95	1.08	1.12	1.24
Academic B	Mean	2.99	2.58	2.99	3.88	2.69	2.00	2.58	2.13	1.65	3.29	4.33
	SD	0.36	0.70	0.80	0.29	0.80	0.35	0.92	0.88	0.78	1.01	0.82
Community A	Mean	2.86	2.61	2.51	3.23	2.73	3.03	2.88	2.84	2.95	3.23	2.66
	SD	0.75	0.79	0.68	1.21	1.11	1.14	1.37	1.17	0.98	1.24	1.15
Community B	Mean	2.86	2.74	2.97	3.37	2.67	2.44	3.28	2.35	2.70	2.50	2.25
	SD	0.67	0.55	0.86	1.04	0.94	0.87	1.00	1.15	1.40	0.72	1.26
Community C	Mean	2.70	2.56	2.64	2.99	2.47	2.53	3.03	2.79	3.07	2.68	2.15
	SD	0.49	0.53	0.67	0.85	0.73	0.64	1.08	0.76	1.05	1.07	0.71
Academic combined	Mean	2.80	2.45	2.93	3.22	2.56	2.24	3.07	2.62	2.88	3.21	3.28
	SD	0.54	0.63	0.66	0.89	0.82	0.72	1.16	0.95	1.14	1.10	1.26
Community combined	Mean	2.79	2.61	2.66	3.14	2.60	2.68	3.03	2.72	2.95	2.82	2.34
	SD	0.62	0.62	0.72	1.01	0.90	0.90	1.15	0.99	1.09	1.09	1.00
P value	>0.05	>0.05	>0.05	>0.05	>0.05	0.02	>0.05	>0.05	>0.05	>0.05	<0.001

DISCUSSION

The HMI is a validated tool that objectively measures and quantifies hospitalist morale. The HMI's capacity to comprehensively assess morale comes from its breadth and depth in uncovering work‐related areas that may be sources of contentment or displeasure. Furthermore, the fact that HMI scores varied among groups of individuals, including those who are thinking about leaving their hospitalist group because they are unhappy and those who are highly invested in their hospitalist group, speaks to its ability to highlight and account for what is most important to hospitalist providers.

Low employee morale has been associated with decreased productivity, increased absenteeism, increased turnover, and decreased patient satisfaction.[2, 26, 27, 28] A few frustrated workers can breed group discontentment and lower the entire group's morale.[28] In addition to its financial impact, departures due to low morale can be sudden and devastating, leading to loss of team cohesiveness, increased work burden on the remaining workforce, burnout, and cascades of more turnover.[2] In contrast, when morale is high, workers more commonly go the extra mile, are more committed to the organization's mission, and are more supportive of their coworkers.[28]

While we asked the informants about plans to leave their job, there are many factors that drive an individual's intent and ultimate decision to make changes in his or her employment. Some factors are outside the control of the employer or practice leaders, such as change in an individual's family life or desire and opportunity to pursue fellowship training. Others variables, however, are more directly tied to the job or practice environment. In a specialty where providers are relatively mobile and turnover is high, it is important for hospitalist practices to cultivate a climate in which the sacrifices associated with leaving outweigh the promised benefits.[29]

Results from the HMPWS suggested the need to address climate and fairness issues in hospitalist programs to improve satisfaction and retention.[9] Two large healthcare systems achieved success by investing in multipronged physician retention strategies including recruiting advisors, sign‐on bonuses, extensive onboarding, family support, and the promotion of ongoing effective communication.[3, 30]

Our findings suggest that morale for hospitalists is a complex amalgam of contentment and importance, and that there may not be a one size fits all solution to improving morale for all. While we did not find a difference in personal morale scores across individual hospitalist groups, or even between academic and community groups, each group had a unique profile with variability in the dynamics between importance and contentment of different factors. If practice group leaders review HMI data for their providers and use the information to facilitate meaningful dialogue with them about the factors influencing their morale, such leaders will have great insight into allocating resources for the best return on investment.

While we believe that the HMI is providing unique perspective compared to other commonly used metrics, it may be best to employ HMI data as complementary measures alongside that of some of the benchmarked scales that explore job satisfaction, job fit, and burnout among hospitalists.[6, 9, 10, 31, 32, 33, 34, 35] Aggregate HMI data at the group level may allow for the identification of factors that are highly important to morale but scored low in contentment. Such factors deserve priority and attention such that the subgroups within a practice can collaborate to come to consensus on strategies for amelioration. Because the HMI generates a score and profile for each provider, we can imagine effective leaders using the HMI with individuals as part of an annual review to facilitate discussion about maximizing contentment at work. Being fully transparent and sharing an honest nonanonymous version of the HMI with a superior would require a special relationship founded on trust and mutual respect.

Several limitations of this study should be considered. First, the initial item reduction and EFA were based on a single‐site survey, and our overall sample size was relatively small. We plan on expanding our sample size in the future for further validation of our exploratory findings. Second, the data were collected at 2 specific times several years ago. In continuing to analyze the data from subsequent years, validity and reliability results remain stable, thereby minimizing the likelihood of significant historical bias. Third, there may have been some recall bias, in that respondents may have overlooked the good and perseverated over variables that disappointed them. Fourth, although intention to leave does not necessarily equate actual employee turnover, intention has been found to be a strong predictor of quitting a job.[36, 37] Finally, while we had high response rates, response bias may have existed wherein those with lower morale may have elected not to complete the survey or became apathetic in their responses.

The HMI is a validated instrument that evaluates hospitalist morale by incorporating each provider's characterization of the importance of and contentment with 27 variables. By accounting for the multidimensional and dynamic nature of morale, the HMI may help program leaders tailor retention and engagement strategies specific to their own group. Future studies may explore trends in contributors to morale and examine whether interventions to augment low morale can result in improved morale and hospitalist retention.

Explosive growth in hospital medicine has led to hospitalists having the option to change jobs easily. Annual turnover for all physicians is 6.8%, whereas that of hospitalists exceeds 14.8%.[1] Losing a single physician has significant financial and operational implications, with estimates of $20,000 to $120,000 in recruiting costs, and up to $500,000 in lost revenue that may take years to recoup due to the time required for new physician assimilation.[2, 3] In 2006, the Society of Hospital Medicine (SHM) appointed a career task force to develop retention recommendations, 1 of which includes monitoring hospitalists' job satisfaction.[4]

Studies examining physician satisfaction have demonstrated that high physician job satisfaction is associated with lower physician turnover.[5] However, surveys of hospitalists, including SHM's Hospital Medicine Physician Worklife Survey (HMPWS), have reported high job satisfaction among hospitalists,[6, 7, 8, 9, 10] suggesting that high job satisfaction may not be enough to overcome forces that pull hospitalists toward other opportunities.

Morale, a more complex construct related to an individual's contentment and happiness, might provide insight into reducing hospitalist turnover. Morale has been defined as the emotional or mental condition with respect to cheerfulness, confidence, or zeal and is especially relevant in the face of opposition or hardship.[11] Job satisfaction is 1 element that contributes to morale, but alone does not equate morale.[12] Morale, more than satisfaction, relates to how people see themselves within the group and may be closely tied to the concept of esprit de corps. To illustrate, workers may feel satisfied with the content of their job, but frustration with the organization may result in low morale.[13] Efforts focused on assessing provider morale may provide deeper understanding of hospitalists' professional needs and garner insight for retention strategies.

The construct of hospitalist morale and its underlying drivers has not been explored in the literature. Using literature within and outside of healthcare,[1, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22] and our own prior work,[23] we sought to characterize elements that contribute to hospitalist morale and develop a metric to measure it. The HMPWS found that job satisfaction factors vary across hospitalist groups.[9] We suspected that the same would hold true for factors important to morale at the individual level. This study describes the development and validation of the Hospitalist Morale Index (HMI), and explores the relationship between morale and intent to leave due to unhappiness.

METHODS

RESULTS

Personal Morale Scores and Factor Scores

Personal morale scores were normally distributed (mean = 2.79; standard deviation [SD] = 0.58), ranging from 1.23 to 4.22, with a theoretical low of 0 and high of 5 (Figure 1). Mean personal morale scores across hospitalist groups ranged from 2.70 to 2.99 (P > 0.05). Personal morale scores, factor sores and item scores for NPs and PAs did not significantly differ from those of physicians (P > 0.05 for all analyses). Personal morale scores were lower for those in their first 3 years with their current group, compared to those with greater institutional longevity. For every categorical increase in a participant's response to seeing oneself as a career hospitalist, the personal morale score rose 0.23 points (P < 0.001).

Figure 1

Factor scores for material reward and mean item scores for professional growth were significantly different across the 5 hospitalist groups (P = 0.03 and P < 0.001, respectively). Community hospitalists had significantly higher factor scores, despite having similar importance scores, for material rewards than academic hospitalists (diff. = 0.44, P = 0.02). Academic hospitalists had significantly higher scores for professional growth (diff. = 0.94, P < 0.001) (Table 2). Professional growth had the highest importance score for academic hospitalists (mean = 0.87, SD = 0.18) and the lowest importance score for community hospitalists (mean = 0.65, SD = 0.24, P < 0.001).

Table 2.Personal Morale Scores, Factor Scores,* and Five Item Scores* by Hospitalist Groups

		Personal Morale Score	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Item 1	Item 2	Item 3	Item 4	Item 5
			Clinical	Workload	Leadership	Appreciation and Acknowledgement	Material Rewards	Family Time	Institutional Climate	Job Security	Autonomy	Professional Growth
NOTE: Abbreviations: SD, standard deviation.*Factor scores and item scores represent the combined product of importance and contentment.
All participants	Mean	2.79	2.54	2.78	3.18	2.58	2.48	3.05	2.67	2.92	3.00	2.76
	SD	0.58	0.63	0.70	0.95	0.86	0.85	1.15	0.97	1.11	1.10	1.21
Academic A	Mean	2.77	2.43	2.92	3.10	2.54	2.28	3.16	2.70	3.06	3.20	3.08
	SD	0.57	0.62	0.64	0.92	0.84	0.77	1.19	0.95	1.08	1.12	1.24
Academic B	Mean	2.99	2.58	2.99	3.88	2.69	2.00	2.58	2.13	1.65	3.29	4.33
	SD	0.36	0.70	0.80	0.29	0.80	0.35	0.92	0.88	0.78	1.01	0.82
Community A	Mean	2.86	2.61	2.51	3.23	2.73	3.03	2.88	2.84	2.95	3.23	2.66
	SD	0.75	0.79	0.68	1.21	1.11	1.14	1.37	1.17	0.98	1.24	1.15
Community B	Mean	2.86	2.74	2.97	3.37	2.67	2.44	3.28	2.35	2.70	2.50	2.25
	SD	0.67	0.55	0.86	1.04	0.94	0.87	1.00	1.15	1.40	0.72	1.26
Community C	Mean	2.70	2.56	2.64	2.99	2.47	2.53	3.03	2.79	3.07	2.68	2.15
	SD	0.49	0.53	0.67	0.85	0.73	0.64	1.08	0.76	1.05	1.07	0.71
Academic combined	Mean	2.80	2.45	2.93	3.22	2.56	2.24	3.07	2.62	2.88	3.21	3.28
	SD	0.54	0.63	0.66	0.89	0.82	0.72	1.16	0.95	1.14	1.10	1.26
Community combined	Mean	2.79	2.61	2.66	3.14	2.60	2.68	3.03	2.72	2.95	2.82	2.34
	SD	0.62	0.62	0.72	1.01	0.90	0.90	1.15	0.99	1.09	1.09	1.00
P value	>0.05	>0.05	>0.05	>0.05	>0.05	0.02	>0.05	>0.05	>0.05	>0.05	<0.001

DISCUSSION

The HMI is a validated tool that objectively measures and quantifies hospitalist morale. The HMI's capacity to comprehensively assess morale comes from its breadth and depth in uncovering work‐related areas that may be sources of contentment or displeasure. Furthermore, the fact that HMI scores varied among groups of individuals, including those who are thinking about leaving their hospitalist group because they are unhappy and those who are highly invested in their hospitalist group, speaks to its ability to highlight and account for what is most important to hospitalist providers.

Low employee morale has been associated with decreased productivity, increased absenteeism, increased turnover, and decreased patient satisfaction.[2, 26, 27, 28] A few frustrated workers can breed group discontentment and lower the entire group's morale.[28] In addition to its financial impact, departures due to low morale can be sudden and devastating, leading to loss of team cohesiveness, increased work burden on the remaining workforce, burnout, and cascades of more turnover.[2] In contrast, when morale is high, workers more commonly go the extra mile, are more committed to the organization's mission, and are more supportive of their coworkers.[28]

While we asked the informants about plans to leave their job, there are many factors that drive an individual's intent and ultimate decision to make changes in his or her employment. Some factors are outside the control of the employer or practice leaders, such as change in an individual's family life or desire and opportunity to pursue fellowship training. Others variables, however, are more directly tied to the job or practice environment. In a specialty where providers are relatively mobile and turnover is high, it is important for hospitalist practices to cultivate a climate in which the sacrifices associated with leaving outweigh the promised benefits.[29]

Results from the HMPWS suggested the need to address climate and fairness issues in hospitalist programs to improve satisfaction and retention.[9] Two large healthcare systems achieved success by investing in multipronged physician retention strategies including recruiting advisors, sign‐on bonuses, extensive onboarding, family support, and the promotion of ongoing effective communication.[3, 30]

Our findings suggest that morale for hospitalists is a complex amalgam of contentment and importance, and that there may not be a one size fits all solution to improving morale for all. While we did not find a difference in personal morale scores across individual hospitalist groups, or even between academic and community groups, each group had a unique profile with variability in the dynamics between importance and contentment of different factors. If practice group leaders review HMI data for their providers and use the information to facilitate meaningful dialogue with them about the factors influencing their morale, such leaders will have great insight into allocating resources for the best return on investment.

While we believe that the HMI is providing unique perspective compared to other commonly used metrics, it may be best to employ HMI data as complementary measures alongside that of some of the benchmarked scales that explore job satisfaction, job fit, and burnout among hospitalists.[6, 9, 10, 31, 32, 33, 34, 35] Aggregate HMI data at the group level may allow for the identification of factors that are highly important to morale but scored low in contentment. Such factors deserve priority and attention such that the subgroups within a practice can collaborate to come to consensus on strategies for amelioration. Because the HMI generates a score and profile for each provider, we can imagine effective leaders using the HMI with individuals as part of an annual review to facilitate discussion about maximizing contentment at work. Being fully transparent and sharing an honest nonanonymous version of the HMI with a superior would require a special relationship founded on trust and mutual respect.

Several limitations of this study should be considered. First, the initial item reduction and EFA were based on a single‐site survey, and our overall sample size was relatively small. We plan on expanding our sample size in the future for further validation of our exploratory findings. Second, the data were collected at 2 specific times several years ago. In continuing to analyze the data from subsequent years, validity and reliability results remain stable, thereby minimizing the likelihood of significant historical bias. Third, there may have been some recall bias, in that respondents may have overlooked the good and perseverated over variables that disappointed them. Fourth, although intention to leave does not necessarily equate actual employee turnover, intention has been found to be a strong predictor of quitting a job.[36, 37] Finally, while we had high response rates, response bias may have existed wherein those with lower morale may have elected not to complete the survey or became apathetic in their responses.

The HMI is a validated instrument that evaluates hospitalist morale by incorporating each provider's characterization of the importance of and contentment with 27 variables. By accounting for the multidimensional and dynamic nature of morale, the HMI may help program leaders tailor retention and engagement strategies specific to their own group. Future studies may explore trends in contributors to morale and examine whether interventions to augment low morale can result in improved morale and hospitalist retention.

Explosive growth in hospital medicine has led to hospitalists having the option to change jobs easily. Annual turnover for all physicians is 6.8%, whereas that of hospitalists exceeds 14.8%.[1] Losing a single physician has significant financial and operational implications, with estimates of $20,000 to $120,000 in recruiting costs, and up to $500,000 in lost revenue that may take years to recoup due to the time required for new physician assimilation.[2, 3] In 2006, the Society of Hospital Medicine (SHM) appointed a career task force to develop retention recommendations, 1 of which includes monitoring hospitalists' job satisfaction.[4]

Studies examining physician satisfaction have demonstrated that high physician job satisfaction is associated with lower physician turnover.[5] However, surveys of hospitalists, including SHM's Hospital Medicine Physician Worklife Survey (HMPWS), have reported high job satisfaction among hospitalists,[6, 7, 8, 9, 10] suggesting that high job satisfaction may not be enough to overcome forces that pull hospitalists toward other opportunities.

Morale, a more complex construct related to an individual's contentment and happiness, might provide insight into reducing hospitalist turnover. Morale has been defined as the emotional or mental condition with respect to cheerfulness, confidence, or zeal and is especially relevant in the face of opposition or hardship.[11] Job satisfaction is 1 element that contributes to morale, but alone does not equate morale.[12] Morale, more than satisfaction, relates to how people see themselves within the group and may be closely tied to the concept of esprit de corps. To illustrate, workers may feel satisfied with the content of their job, but frustration with the organization may result in low morale.[13] Efforts focused on assessing provider morale may provide deeper understanding of hospitalists' professional needs and garner insight for retention strategies.

The construct of hospitalist morale and its underlying drivers has not been explored in the literature. Using literature within and outside of healthcare,[1, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22] and our own prior work,[23] we sought to characterize elements that contribute to hospitalist morale and develop a metric to measure it. The HMPWS found that job satisfaction factors vary across hospitalist groups.[9] We suspected that the same would hold true for factors important to morale at the individual level. This study describes the development and validation of the Hospitalist Morale Index (HMI), and explores the relationship between morale and intent to leave due to unhappiness.

METHODS

RESULTS

Personal Morale Scores and Factor Scores

Personal morale scores were normally distributed (mean = 2.79; standard deviation [SD] = 0.58), ranging from 1.23 to 4.22, with a theoretical low of 0 and high of 5 (Figure 1). Mean personal morale scores across hospitalist groups ranged from 2.70 to 2.99 (P > 0.05). Personal morale scores, factor sores and item scores for NPs and PAs did not significantly differ from those of physicians (P > 0.05 for all analyses). Personal morale scores were lower for those in their first 3 years with their current group, compared to those with greater institutional longevity. For every categorical increase in a participant's response to seeing oneself as a career hospitalist, the personal morale score rose 0.23 points (P < 0.001).

Figure 1

Factor scores for material reward and mean item scores for professional growth were significantly different across the 5 hospitalist groups (P = 0.03 and P < 0.001, respectively). Community hospitalists had significantly higher factor scores, despite having similar importance scores, for material rewards than academic hospitalists (diff. = 0.44, P = 0.02). Academic hospitalists had significantly higher scores for professional growth (diff. = 0.94, P < 0.001) (Table 2). Professional growth had the highest importance score for academic hospitalists (mean = 0.87, SD = 0.18) and the lowest importance score for community hospitalists (mean = 0.65, SD = 0.24, P < 0.001).

Table 2.Personal Morale Scores, Factor Scores,* and Five Item Scores* by Hospitalist Groups

		Personal Morale Score	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Item 1	Item 2	Item 3	Item 4	Item 5
			Clinical	Workload	Leadership	Appreciation and Acknowledgement	Material Rewards	Family Time	Institutional Climate	Job Security	Autonomy	Professional Growth
NOTE: Abbreviations: SD, standard deviation.*Factor scores and item scores represent the combined product of importance and contentment.
All participants	Mean	2.79	2.54	2.78	3.18	2.58	2.48	3.05	2.67	2.92	3.00	2.76
	SD	0.58	0.63	0.70	0.95	0.86	0.85	1.15	0.97	1.11	1.10	1.21
Academic A	Mean	2.77	2.43	2.92	3.10	2.54	2.28	3.16	2.70	3.06	3.20	3.08
	SD	0.57	0.62	0.64	0.92	0.84	0.77	1.19	0.95	1.08	1.12	1.24
Academic B	Mean	2.99	2.58	2.99	3.88	2.69	2.00	2.58	2.13	1.65	3.29	4.33
	SD	0.36	0.70	0.80	0.29	0.80	0.35	0.92	0.88	0.78	1.01	0.82
Community A	Mean	2.86	2.61	2.51	3.23	2.73	3.03	2.88	2.84	2.95	3.23	2.66
	SD	0.75	0.79	0.68	1.21	1.11	1.14	1.37	1.17	0.98	1.24	1.15
Community B	Mean	2.86	2.74	2.97	3.37	2.67	2.44	3.28	2.35	2.70	2.50	2.25
	SD	0.67	0.55	0.86	1.04	0.94	0.87	1.00	1.15	1.40	0.72	1.26
Community C	Mean	2.70	2.56	2.64	2.99	2.47	2.53	3.03	2.79	3.07	2.68	2.15
	SD	0.49	0.53	0.67	0.85	0.73	0.64	1.08	0.76	1.05	1.07	0.71
Academic combined	Mean	2.80	2.45	2.93	3.22	2.56	2.24	3.07	2.62	2.88	3.21	3.28
	SD	0.54	0.63	0.66	0.89	0.82	0.72	1.16	0.95	1.14	1.10	1.26
Community combined	Mean	2.79	2.61	2.66	3.14	2.60	2.68	3.03	2.72	2.95	2.82	2.34
	SD	0.62	0.62	0.72	1.01	0.90	0.90	1.15	0.99	1.09	1.09	1.00
P value	>0.05	>0.05	>0.05	>0.05	>0.05	0.02	>0.05	>0.05	>0.05	>0.05	<0.001

DISCUSSION

The HMI is a validated tool that objectively measures and quantifies hospitalist morale. The HMI's capacity to comprehensively assess morale comes from its breadth and depth in uncovering work‐related areas that may be sources of contentment or displeasure. Furthermore, the fact that HMI scores varied among groups of individuals, including those who are thinking about leaving their hospitalist group because they are unhappy and those who are highly invested in their hospitalist group, speaks to its ability to highlight and account for what is most important to hospitalist providers.

Low employee morale has been associated with decreased productivity, increased absenteeism, increased turnover, and decreased patient satisfaction.[2, 26, 27, 28] A few frustrated workers can breed group discontentment and lower the entire group's morale.[28] In addition to its financial impact, departures due to low morale can be sudden and devastating, leading to loss of team cohesiveness, increased work burden on the remaining workforce, burnout, and cascades of more turnover.[2] In contrast, when morale is high, workers more commonly go the extra mile, are more committed to the organization's mission, and are more supportive of their coworkers.[28]

While we asked the informants about plans to leave their job, there are many factors that drive an individual's intent and ultimate decision to make changes in his or her employment. Some factors are outside the control of the employer or practice leaders, such as change in an individual's family life or desire and opportunity to pursue fellowship training. Others variables, however, are more directly tied to the job or practice environment. In a specialty where providers are relatively mobile and turnover is high, it is important for hospitalist practices to cultivate a climate in which the sacrifices associated with leaving outweigh the promised benefits.[29]

Results from the HMPWS suggested the need to address climate and fairness issues in hospitalist programs to improve satisfaction and retention.[9] Two large healthcare systems achieved success by investing in multipronged physician retention strategies including recruiting advisors, sign‐on bonuses, extensive onboarding, family support, and the promotion of ongoing effective communication.[3, 30]

Our findings suggest that morale for hospitalists is a complex amalgam of contentment and importance, and that there may not be a one size fits all solution to improving morale for all. While we did not find a difference in personal morale scores across individual hospitalist groups, or even between academic and community groups, each group had a unique profile with variability in the dynamics between importance and contentment of different factors. If practice group leaders review HMI data for their providers and use the information to facilitate meaningful dialogue with them about the factors influencing their morale, such leaders will have great insight into allocating resources for the best return on investment.

While we believe that the HMI is providing unique perspective compared to other commonly used metrics, it may be best to employ HMI data as complementary measures alongside that of some of the benchmarked scales that explore job satisfaction, job fit, and burnout among hospitalists.[6, 9, 10, 31, 32, 33, 34, 35] Aggregate HMI data at the group level may allow for the identification of factors that are highly important to morale but scored low in contentment. Such factors deserve priority and attention such that the subgroups within a practice can collaborate to come to consensus on strategies for amelioration. Because the HMI generates a score and profile for each provider, we can imagine effective leaders using the HMI with individuals as part of an annual review to facilitate discussion about maximizing contentment at work. Being fully transparent and sharing an honest nonanonymous version of the HMI with a superior would require a special relationship founded on trust and mutual respect.

Several limitations of this study should be considered. First, the initial item reduction and EFA were based on a single‐site survey, and our overall sample size was relatively small. We plan on expanding our sample size in the future for further validation of our exploratory findings. Second, the data were collected at 2 specific times several years ago. In continuing to analyze the data from subsequent years, validity and reliability results remain stable, thereby minimizing the likelihood of significant historical bias. Third, there may have been some recall bias, in that respondents may have overlooked the good and perseverated over variables that disappointed them. Fourth, although intention to leave does not necessarily equate actual employee turnover, intention has been found to be a strong predictor of quitting a job.[36, 37] Finally, while we had high response rates, response bias may have existed wherein those with lower morale may have elected not to complete the survey or became apathetic in their responses.

The HMI is a validated instrument that evaluates hospitalist morale by incorporating each provider's characterization of the importance of and contentment with 27 variables. By accounting for the multidimensional and dynamic nature of morale, the HMI may help program leaders tailor retention and engagement strategies specific to their own group. Future studies may explore trends in contributors to morale and examine whether interventions to augment low morale can result in improved morale and hospitalist retention.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

Testing for breast cancer is traditionally offered in outpatient settings, and screening mammography rates have plateaued since 2000.[1] Current data suggest that the mammography utilization gap by race has narrowed; however, disparity remains among low‐income, uninsured, and underinsured populations.[2, 3] The lowest compliance with screening mammography recommendations have been reported among women with low income (63.2%), uninsured (50.4%), and those without a usual source of healthcare (43.6%).[4] Although socioeconomic status, access to the healthcare system, and awareness about screening benefits can all influence women's willingness to have screening, the most common reason that women report for not having mammograms were that no one recommended the test.[5, 6] These findings support previous reports that physicians' recommendations about the need for screening mammography is an influential factor in determining women's decisions related to compliance.[7] Hence, the role of healthcare providers in all clinical care settings is pivotal in reducing mammography utilization disparities.

A recent study evaluating the breast cancer screening adherence among the hospitalized women aged 50 to 75 years noted that many (60%) were low income (annual household income <$20,000), 39% were nonadherent, and 35% were at high risk of developing breast cancer.[8] Further, a majority of these hospitalized women were amenable to inpatient screening mammography if due and offered during the hospital stay.[8] As a follow‐up, the purpose of the current study was to explore how hospitalists feel about getting involved in breast cancer screening and ordering screening mammograms for hospitalized women. We hypothesized that a greater proportion of hospitalists would order mammography for hospitalized women who were both overdue for screening and at high risk for developing breast cancer if they fundamentally believe that they have a role in breast cancer screening. This study also explored anticipated barriers that may be of concern to hospitalists when ordering inpatient screening mammography.

METHODS

RESULTS

Out of 106 study subjects willing to participate, 8 did not respond, yielding a response rate of 92%. The mean age of the study participants was 37.6 years, and 55% were female. Almost two‐thirds of study participants (59%) were faculty physicians at an academic hospital, and the average clinical experience as a hospitalist was 4.6 years. Study participants were diverse with respect to ethnicity, and only 30% reported having a family member with breast cancer (Table 1). Because breast cancer is a disease that affects primarily women, stratified analysis by gender showed that most of these characteristic were similar across genders, except fewer women were full time (76% vs 93%, P=0.04) and on the faculty (44% vs 77%, P=0.003).

Only 38% believed that hospitalists should be involved with breast cancer screening. The most commonly cited concern related to ordering an inpatient screening mammography was follow‐up of the results of the mammography, followed by the test may not be covered by patient's insurance. As shown in Table 2, these concerns were not perceived differently among providers who believed that hospitalists should be involved in breast cancer screening as compared to those who do not. Demographic variables from Table 1 failed to discern any significant associations related to believing that hospitalists should be involved with breast cancer screening or with concerns about the barriers to screening presented in Table 2 (data not shown). As shown in Table 2, overall, 32% hospitalists were willing to order a screening mammography during a hospital stay for the scenario of the woman at high risk for developing breast cancer (5‐year risk prediction using Gail model 2.1%) and 33% for the low‐risk scenario (5‐year risk prediction using Gail model 0.6%).

DISCUSSION

Our study suggests that most hospitalists do not believe that they should be involved in breast cancer screening for their hospitalized patients. This perspective was not influenced by either the physician gender, family history for breast cancer, or by the patient's level of risk for developing breast cancer. When patients are in the hospital, both the setting and the acute illness are known to promote reflection and consideration of self‐care.[10] With major healthcare system changes on the horizon and the passing of the Affordable Care Act, we are becoming teams of providers who are collectively responsible for optimal care delivery. It may be possible to increase breast cancer screening rates by educating our patients and offering inpatient screening mammography while they are in the hospital, particularly to those who are at high risk of developing breast cancer.

Physician recommendations for preventive health and screening have consistently been found to be among the strongest predictors of screening utilization.[11] This is the first study to our knowledge that has attempted to understand hospitalists' views and concerns about ordering screening tests to detect occult malignancy. Although addressing preventive care during a hospitalization may seem complex and difficult, helping these women understand their personal risk profile (eg, family history of breast cancer, use of estrogen, race, age, and genetic risk factors) may be what is needed for beginning to influence perspective that might ultimately translate into a willingness to undergo screening.[12, 13, 14] Such delivery of patient‐centered care is built on a foundation of shared decision‐making, which takes into account the patient's preferences, values, and wishes.[15]

Ordering screening mammography for hospitalized patients will require a deeper understanding of hospitalists' attitudes, because the way that these physicians feel about the tests utility will dramatically influence the way that this opportunity is presented to patients, and ultimately the patients' preference to have or forego testing. Our study results are consistent with another publication that highlighted incongruence between physicians' views and patients' preferences for screening practices.[8, 11] Concerns cited, such as interference with patient's acute care, deserve attention, because it may be possible to carry out the screening in ways and at times that do not interfere with treatment or prolong length of stay. Exploring this with a feasibility study will be necessary. Such an approach has been advocated by Trimble et al. for inpatient cervical cancer screening as an efficient strategy to target high‐risk, nonadherent women.[16]

The inpatient setting allows for the elimination of major barriers to screening (like transportation and remembering to get to screening appointments),[8] thereby actively facilitating this needed service. Costs associated with inpatient screening mammography may deter both hospitalists and patients from screening; however, some insurers and Medicare pay for the full cost of screening tests, irrespective of the clinical setting.[17] Further, as hospitals or accountable care organizations become responsible for total cost per beneficiary, screening costs will be preferable when compared with the expenses associated with later detection of pathology and caring for advanced disease states.

One might question whether the mortality benefit of screening mammography is comparable among hospitalized women (who are theoretically sicker and with shorter life expectancy) and those cared for in outpatient practices. Unfortunately, we do not yet know the answer to this question, because data for inpatient screening mammography are nonexistent, and currently this is not considered as a standard of care. However, one can expect the benefits to be similar, if not greater, when performed in the outpatient setting, if preliminary efforts are directed at those who are both nonadherent and at high risk for breast cancer. According to 1 study, increasing mammography utilization by 5% in our country would prevent 560 deaths from breast cancer each year.[18]

Several limitations of this study should be considered. First, this cross‐sectional study was conducted at hospitals associated with a single institution and the results may not be generalizable. Second, although physicians' concerns were explored in this study, we did not solicit input about the potential impact of prevention and screening on the nursing staff. Third, there may be concerns about the hypothetical nature of anchoring and possible framing effects with the 2 clinical scenarios. Finally, it is possible that the hospitalists' response may have been subject to social desirability bias. That said, the response to the key question Do you think hospitalists should be involved in breast cancer screening? do not support a socially desirable bias.

Given the current policy emphasis on reducing disparities in cancer screening, it may be reasonable to expand the role of all healthcare providers and healthcare facilities in screening high‐risk populations. Screening tests that may seem difficult to coordinate in hospitals currently may become easier as our hospitals evolve to become more patient centered. Future studies are needed to evaluate the feasibility and potential barriers to inpatient screening mammography.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

Physicians assume myriad leadership roles within medical institutions. Clinically‐oriented leadership roles can range from managing a small group of providers, to leading entire health systems, to heading up national quality improvement initiatives. While often competent in the practice of medicine, many physicians have not pursued structured management or administrative training. In a survey of Medicine Department Chairs at academic medical centers, none had advanced management degrees despite spending an average of 55% of their time on administrative duties. It is not uncommon for physicians to attend leadership development programs or management seminars, as evidenced by the increasing demand for education.1 Various methods for skill enhancement have been described24; however, the most effective approaches have yet to be determined.

Miller and Dollard5 and Bandura6, 7 have explained that behavioral contracts have evolved from social cognitive theory principles. These contracts are formal written agreements, often negotiated between 2 individuals, to facilitate behavior change. Typically, they involve a clear definition of expected behaviors with specific consequences (usually positive reinforcement).810 Their use in modifying physician behavior, particularly those related to leadership, has not been studied.

Hospitalist physicians represent the fastest growing specialty in the United States.11, 12 Among other responsibilities, they have taken on roles as leaders in hospital administration, education, quality improvement, and public health.1315 The Society of Hospital Medicine (SHM), the largest US organization committed to the practice of hospital medicine,16 has established Leadership Academies to prepare hospitalists for these duties. The goal of this study was to assess how hospitalist physicians' commitment to grow as leaders was expressed using behavioral contacts as a vehicle to clarify their intentions and whether behavioral change occurred over time.

Methods

Results

Follow‐up Data About Adherence to Plans Delineated in Behavioral Contracts

Out of 65 completed behavioral contracts from the 2007 Level I participants, 32 returned a follow‐up survey (response rate 49.3%). Figure 1 shows the extent to which respondents believed that they were compliant with their proposed plans for change or improvement. Degree of adherence was displayed as a proportion of total goals. Out of those who returned a follow‐up survey, all but 1 respondent either strongly agreed or agreed that they adhered to at least one of their goals (96.9%).

Figure 1

Select representative comments that illustrate the physicians' appreciation of using behavioral contracts include:

• my approach to problems is a bit more analytical.

• simple changes in how I approach people and interact with them has greatly improved my skills as a leader and allowed me to accomplish my goals with much less effort.

 

Discussion

Through the qualitative analysis of the behavioral contracts completed by participants of a Leadership Academy for hospitalists, we characterized the ways that hospitalist practitioners hoped to evolve as leaders. The major themes that emerged relate not only to their own growth and development but also their pledge to advance the success of the group or division. The level of commitment and impact of the behavioral contracts appear to be reinforced by an overwhelmingly positive response to adherence to personal goals one year after course participation. Communication and interpersonal development were most frequently cited in the behavioral contracts as areas for which the hospitalist leaders acknowledged a desire to grow. In a study of academic department of medicine chairs, communication skills were identified as being vital for effective leadership.3 The Chairs also recognized other proficiencies required for leading that were consistent with those outlined in the behavioral contracts: strategic planning, change management, team building, personnel management, and systems thinking. McDade et al.17 examined the effects of participation in an executive leadership program developed for female academic faculty in medical and dental schools in the United States and Canada. They noted increased self‐assessed leadership capabilities at 18 months after attending the program, across 10 leadership constructs taught in the classes. These leadership constructs resonate with the themes found in the plans for change described by our informants.

Hospitalists are assuming leadership roles in an increasing number and with greater scope; however, until now their perspectives on what skill sets are required to be successful have not been well documented. Significant time, effort, and money are invested into the development of hospitalists as leaders.4 The behavioral contract appears to be a tool acceptable to hospitalist physicians; perhaps it can be used as part annual reviews with hospitalists aspiring to be leaders.

Several limitations of the study shall be considered. First, not all participants attending the Leadership Academy opted to fill out the behavioral contracts. Second, this qualitative study is limited to those practitioners who are genuinely interested in growing as leaders as evidenced by their willingness to invest in going to the course. Third, follow‐up surveys relied on self‐assessment and it is not known whether actual realization of these goals occurred or the extent to which behavioral contracts were responsible. Further, follow‐up data were only completed by 49% percent of those targeted. However, hospitalists may be fairly resistant to being surveyed as evidenced by the fact that SHM's 2005‐2006 membership survey yielded a response rate of only 26%.18 Finally, many of the thematic goals were described by fewer than 50% of informants. However, it is important to note that the elements included on each person's behavioral contract emerged spontaneously. If subjects were specifically asked about each theme, the number of comments related to each would certainly be much higher. Qualitative analysis does not really allow us to know whether one theme is more important than another merely because it was mentioned more frequently.

Hospitalist leaders appear to be committed to professional growth and they have reported realization of goals delineated in their behavioral contracts. While varied methods are being used as part of physician leadership training programs, behavioral contracts may enhance promise for change.

Physicians assume myriad leadership roles within medical institutions. Clinically‐oriented leadership roles can range from managing a small group of providers, to leading entire health systems, to heading up national quality improvement initiatives. While often competent in the practice of medicine, many physicians have not pursued structured management or administrative training. In a survey of Medicine Department Chairs at academic medical centers, none had advanced management degrees despite spending an average of 55% of their time on administrative duties. It is not uncommon for physicians to attend leadership development programs or management seminars, as evidenced by the increasing demand for education.1 Various methods for skill enhancement have been described24; however, the most effective approaches have yet to be determined.

Miller and Dollard5 and Bandura6, 7 have explained that behavioral contracts have evolved from social cognitive theory principles. These contracts are formal written agreements, often negotiated between 2 individuals, to facilitate behavior change. Typically, they involve a clear definition of expected behaviors with specific consequences (usually positive reinforcement).810 Their use in modifying physician behavior, particularly those related to leadership, has not been studied.

Hospitalist physicians represent the fastest growing specialty in the United States.11, 12 Among other responsibilities, they have taken on roles as leaders in hospital administration, education, quality improvement, and public health.1315 The Society of Hospital Medicine (SHM), the largest US organization committed to the practice of hospital medicine,16 has established Leadership Academies to prepare hospitalists for these duties. The goal of this study was to assess how hospitalist physicians' commitment to grow as leaders was expressed using behavioral contacts as a vehicle to clarify their intentions and whether behavioral change occurred over time.

Methods

Results

Follow‐up Data About Adherence to Plans Delineated in Behavioral Contracts

Out of 65 completed behavioral contracts from the 2007 Level I participants, 32 returned a follow‐up survey (response rate 49.3%). Figure 1 shows the extent to which respondents believed that they were compliant with their proposed plans for change or improvement. Degree of adherence was displayed as a proportion of total goals. Out of those who returned a follow‐up survey, all but 1 respondent either strongly agreed or agreed that they adhered to at least one of their goals (96.9%).

Figure 1

Select representative comments that illustrate the physicians' appreciation of using behavioral contracts include:

• my approach to problems is a bit more analytical.

• simple changes in how I approach people and interact with them has greatly improved my skills as a leader and allowed me to accomplish my goals with much less effort.

 

Discussion

Through the qualitative analysis of the behavioral contracts completed by participants of a Leadership Academy for hospitalists, we characterized the ways that hospitalist practitioners hoped to evolve as leaders. The major themes that emerged relate not only to their own growth and development but also their pledge to advance the success of the group or division. The level of commitment and impact of the behavioral contracts appear to be reinforced by an overwhelmingly positive response to adherence to personal goals one year after course participation. Communication and interpersonal development were most frequently cited in the behavioral contracts as areas for which the hospitalist leaders acknowledged a desire to grow. In a study of academic department of medicine chairs, communication skills were identified as being vital for effective leadership.3 The Chairs also recognized other proficiencies required for leading that were consistent with those outlined in the behavioral contracts: strategic planning, change management, team building, personnel management, and systems thinking. McDade et al.17 examined the effects of participation in an executive leadership program developed for female academic faculty in medical and dental schools in the United States and Canada. They noted increased self‐assessed leadership capabilities at 18 months after attending the program, across 10 leadership constructs taught in the classes. These leadership constructs resonate with the themes found in the plans for change described by our informants.

Hospitalists are assuming leadership roles in an increasing number and with greater scope; however, until now their perspectives on what skill sets are required to be successful have not been well documented. Significant time, effort, and money are invested into the development of hospitalists as leaders.4 The behavioral contract appears to be a tool acceptable to hospitalist physicians; perhaps it can be used as part annual reviews with hospitalists aspiring to be leaders.

Several limitations of the study shall be considered. First, not all participants attending the Leadership Academy opted to fill out the behavioral contracts. Second, this qualitative study is limited to those practitioners who are genuinely interested in growing as leaders as evidenced by their willingness to invest in going to the course. Third, follow‐up surveys relied on self‐assessment and it is not known whether actual realization of these goals occurred or the extent to which behavioral contracts were responsible. Further, follow‐up data were only completed by 49% percent of those targeted. However, hospitalists may be fairly resistant to being surveyed as evidenced by the fact that SHM's 2005‐2006 membership survey yielded a response rate of only 26%.18 Finally, many of the thematic goals were described by fewer than 50% of informants. However, it is important to note that the elements included on each person's behavioral contract emerged spontaneously. If subjects were specifically asked about each theme, the number of comments related to each would certainly be much higher. Qualitative analysis does not really allow us to know whether one theme is more important than another merely because it was mentioned more frequently.

Hospitalist leaders appear to be committed to professional growth and they have reported realization of goals delineated in their behavioral contracts. While varied methods are being used as part of physician leadership training programs, behavioral contracts may enhance promise for change.

Physicians assume myriad leadership roles within medical institutions. Clinically‐oriented leadership roles can range from managing a small group of providers, to leading entire health systems, to heading up national quality improvement initiatives. While often competent in the practice of medicine, many physicians have not pursued structured management or administrative training. In a survey of Medicine Department Chairs at academic medical centers, none had advanced management degrees despite spending an average of 55% of their time on administrative duties. It is not uncommon for physicians to attend leadership development programs or management seminars, as evidenced by the increasing demand for education.1 Various methods for skill enhancement have been described24; however, the most effective approaches have yet to be determined.

Miller and Dollard5 and Bandura6, 7 have explained that behavioral contracts have evolved from social cognitive theory principles. These contracts are formal written agreements, often negotiated between 2 individuals, to facilitate behavior change. Typically, they involve a clear definition of expected behaviors with specific consequences (usually positive reinforcement).810 Their use in modifying physician behavior, particularly those related to leadership, has not been studied.

Hospitalist physicians represent the fastest growing specialty in the United States.11, 12 Among other responsibilities, they have taken on roles as leaders in hospital administration, education, quality improvement, and public health.1315 The Society of Hospital Medicine (SHM), the largest US organization committed to the practice of hospital medicine,16 has established Leadership Academies to prepare hospitalists for these duties. The goal of this study was to assess how hospitalist physicians' commitment to grow as leaders was expressed using behavioral contacts as a vehicle to clarify their intentions and whether behavioral change occurred over time.