Community hospitals branch out to clinical research

Clinical research at community hospitals in collaboration with academic medical facilities is gaining traction around the U.S.

Bernardo Obeso, MD, had a great job as a general internist in private clinical practice, as well as a teaching position at Advocate Illinois Masonic Medical Center in Chicago. Still, something was missing: he longed to do research.

So Dr. Obeso looked around the country, and landed a new job in Atlantis, Fla., last May—but not, as you might expect, doing research at an academic institution. He now works as a community hospitalist at JFK Medical Center, directing residents of the University of Miami—where he is on the faculty—and devoting 30% of his time to clinical research.


“I was always interested in having … protected time to develop clinical research,” Dr. Obeso said in explaining his job switch. He and his colleagues at JFK Medical Center will soon carry handheld ultrasound devices to detect left ventricular cardiac dysfunction as part of a joint research effort with the University of Miami's Miller School of Medicine and three other institutions.

The term “community hospitalist/clinical researcher” may once have seemed an oxymoron, but the practice of doing clinical research at community hospitals—usually in collaboration with academic medical facilities—is gaining traction around the U.S. In Chicago, community hospitalists are learning to use genetic information to more rapidly titrate warfarin in a collaborative project with the University of Chicago's Pritzker School of Medicine. Meanwhile, Meriter Hospital in Madison, Wis. is completing a three-year study to test a protocol for preventing blood clots in hospitalized patients, in conjunction with the University of California, San Diego (UCSD).

“Historically, it was only academic hospitalists who conducted scientific research, not community physicians,” said Peter Lindenauer, FACP, director of the Center for Quality of Care Research at Baystate Medical Center in Springfield, Mass, and a widely published hospitalist researcher. “Now both are engaged in scholarship related to the field of hospital medicine.”

Two heads are better than one

Community hospitalists have conducted quality and safety research for many years. But as hospital medicine matures, more and more are teaming up with their academic colleagues as co-investigators in clinical domains as well.

Conducting research is clearly beneficial for community hospitals because it carries prestige and attracts patients. Moreover, it contributes to a community hospital's nonprofit mission, Dr. Lindenauer noted. Partnering with an academic medical center makes sense from a resource perspective, too, said David Lovinger, MD, a University of Chicago hospitalist researcher who is directing the warfarin titration project.

“Doing research is not a home basement activity,” Dr. Lovinger said. “Depending on the project, you may need statisticians, programmers, health economists, geneticists and pharmacologists,” which you may not have access to at a community hospital. Academic facilities have more experienced investigators and grant writers, and are more likely to get funding because they have more expertise in research, Dr. Lovinger added.

Academic physicians and medical students, meanwhile, are eager to partner with community hospitals, because they can apply their research beyond an academic setting and gain credibility. “It's very important to include a range of patients and settings in the creation of research projects for results to be considered ‘generalizable,’” Dr. Lindenauer said. “(For patients), it's an opportunity to participate in beneficial, novel therapies.”

Branching out beyond clinical work also provides career satisfaction and prestige in the field, Dr. Lovinger said. “It's another career path; it gives you something to be an expert in.” Dr. Lovinger devotes most of his time to seeing hospital patients, and spends about 25% on research. Yet he has become an anti-coagulation authority, giving talks at national meetings on the subject. “I like doing different things,” he said.

Time challenges

Finding time to do research can be a challenge for busy community hospitalists, said Scott Flanders, FACP, associate director of inpatient programs at the University of Michigan department of medicine. Dr. Flanders was recently the principal investigator on a project with community hospitalists.

The two-year, $117,000 research program, called Hospitalists as Emerging Leaders in Patient Safety, or HELPS, was supported by the Blue Cross and Blue Shield of Michigan Foundation, and brought together nine Southern Michigan hospitalist programs to discover which safety initiatives worked and why.

“It was challenging getting community hospitalists involved,” Dr. Flanders said. “They are incredibly busy because many hospitalist programs, especially in their early years, are simply unstable, with high rates of turnover. Many of these groups are struggling just to try to deliver day-to-day clinical care, let alone having the time to allow someone to leave the hospital, meet with a group and work on a particular safety project.”

Often, community hospitalists must also set time aside for training in research skills, depending on the demands of the academic affiliate, grantor, or both. Recipients of National Institutes of Health (NIH) grants, for example, are required to take the NIH's one-hour, online course on human subjects ethics.

Hasan Shabbir, MD, a hospitalist at Emory Johns Creek Hospital in Atlanta, was required by Emory University to complete a human subjects course for his pilot study on the outcomes of nightly blood sugar checks. He took a class through the Collaborative Institutional Training Initiative (CITI), which provides short online training courses in research.

A training credential also can be important to gain Institutional Review Board (IRB) approval, which is often required by a grantor in order to do research. “The IRB insures you are conducting human subject research on the highest level of integrity and professionalism and that human subjects are protected from harm,” said Paul Braunschweiger, Ph.D., co-founder of CITI, adding that research conducted without IRB approval has little credibility.

Some community hospitalists earn “protected time” away from clinical responsibilities as a form of payment for their research. But even this may not cover the amount of work needed to do a project.

“Most research is done by people who do it as a full-time endeavor and who have gone through years of training to become investigators,” Dr. Lindenauer said. “If you are a full time practicing hospitalist, it's likely that you will have only 10%-20% of your time—or less—protected, and this is intended to cover a range of activities including quality improvement and education, as well as scholarship.”

Quality improvement projects often offer the surest path to scholarship for community-based hospitalists, he added. Even so, a hospitalist usually must put in a little bit of sweat equity—working on projects after hours and on weekends—in order to be successful.

Cate Ranheim, MD, a community hospitalist at Meriter Hospital in Madison, Wis., knows a lot about sweat equity. She received 15% protected time after applying for a three-year grant from a philanthropic foundation associated with her hospital, but that didn't begin to cover the hours she put in on a blood clot prevention study done with UCSD.

“If you're not careful, research can take over your life,” Dr. Ranheim said. “There were certainly a lot of uncompensated nights and weekends. You have to set parameters.”

In the end, however, she said the effort was rewarding. “I love taking care of patients. But research gives me a chance to affect the whole hospital, the whole community,” Dr. Ranheim said. “I see the effect of the protocols I've created and the research I've done, and I know I've helped many people I'll never meet.”