Baking hospitalist training into residency

Although half of large internal medicine residency programs offer hospitalist-focused rotations, there are no standards for their structure.

In the past, internal medicine residency programs didn't always worry about offering specific training in hospital medicine. When Christopher Sankey, MD, FACP, was interested in high-acuity general medicine at the end of his residency 15 years ago, he figured he'd be an intensivist.

“The only experience that I had baked into my residency training program that showed me high-acuity general medicine was in the ICU,” he said.

Dr. Sankey matched into a critical care fellowship, but his now-wife still had to complete her residency training, so he gave up his fellowship spot and got a hospitalist job. Three months in, he was sold on hospital medicine.

Photo by Thinkstock
Photo by Thinkstock

“If I had had access to a hospital medicine-specific experience as a resident, I think it would've been a lot clearer, and I wouldn't have had to luck into it in the way that I did,” said Dr. Sankey, now associate program director for Yale's internal medicine residency and an academic hospitalist at Yale-New Haven Hospital.

As of this past academic year, he's also the founder of a hospitalist training elective, which 12 Yale residents have completed. Residents choose from a menu of opportunities to customize hospitalist training to their own needs and desires, such as meeting individually with internal medicine-trained administrators or observing rapid response calls and procedures.

These days, more residents have access to such training. In a May 2015 survey of 82 large internal medicine residency programs, 50% of program leaders reported offering hospitalist-focused rotations. Of the programs without hospitalist rotations, about 22% reported plans to implement them, according to results published in March 2018 by the Journal of Hospital Medicine.

But the article also pointed out a chief challenge (and opportunity) inherent in creating the experience: There's no standard for what it should look like. The academic hospitalist leaders who launched early programs had to identify what they considered the most important components of training, and they can now share their insights with those following in their footsteps.

Meeting unmet needs

Despite the potential for variation, most of the elective rotations identified in the survey study were one month in duration and included second- and/or third-year residents. The average length of existence of the rotations was about five years, with a range of one to 15 years. That early-adopting outlier is the University of Colorado in Denver.

The residency program there offers both a two-year hospitalist training track, which holds about 10 residents per year, and a one-month hospital medicine elective that has two residents per month, said Patrick Kneeland, MD, executive medical director for patient and provider experience at UCHealth and director for quality, safety, and efficiency in the University of Colorado's hospital medicine division.

To modernize the elective curriculum in recent years, he worked with others in the division to add some key elements for effective practice in contemporary hospitals to the traditional clinical training. An important component of that has been the health care value equation: quality over cost.

“If folks are going to practice in complex environments where value is key, starting with the health care value equation and building practical pieces around quality, safety, experience, and cost is a great place to start,” said Dr. Kneeland.

At the University of Kentucky in Lexington, the 16-month-long hospital medicine track offers a similar systems-based training program. It is four years old and takes seven residents per year, said track director Joseph R. Sweigart, MD, FACP, an associate professor and associate director for the internal medicine residency program.

While concepts like payer mix and business drivers may not sound thrilling, residents love the introduction to health care finance, said Dr. Sweigart, who completed the University of Colorado's hospitalist track. “These are things that I learned at the University of Colorado but that most residents don't get a lot of exposure to, even though those are the things that absolutely impact their daily lives.”

Six months after graduation, residents from the University of Kentucky fill out surveys about what's been most useful about the track. Graduates, especially those who become hospitalists, give high ratings to lessons about billing and coding, facility fee reimbursement, and evaluation and management physician fee reimbursement, Dr. Sweigart said. “They're saying, ‘My bosses are telling me that I'm outperforming other people who hired in with me, and I think that's the reason.’”

The track also features a mentorship component—each resident is paired with a mentor with similar interests, Dr. Sweigart said. “The residents really love having someone to reach out to if they want someone to look over their CV or review a contract, and the attendings have also really enjoyed having the opportunity to get to know the residents differently than they would as their academic attendings.”

But hospitalist-specific training isn't only occurring at academic centers. Emory Saint Joseph's Hospital, a community hospital in Atlanta, has welcomed residents from Emory University School of Medicine's program for a one-month hospital medicine elective for about two years, said Michele Sundar, MD, ACP Member, site assistant director for education. Two weeks are devoted to clinical practice, and the rest of the rotation focuses on what hospitalists do besides seeing patients, such as attending committee meetings and learning from documentation specialists, she said.

“They do all these other activities that really show you what the life of a hospitalist can be, should you choose to do something beyond showing up for work and seeing your patients and going home,” Dr. Sundar said. “That's what they don't get at a [standard] academic setting: You just see your attending on wards, they round, they kind of go away later in the day, and you don't know what they're doing.”

In the survey study, the majority of hospitalist rotation leaders said that the programs fill a training gap by allowing for progressive clinical autonomy. However, at her community hospital where residents are dealing with an unfamiliar system, tasks like calling consults have a learning curve and can actually lead to a sense of less autonomy, Dr. Sundar noted.

“It's not as easy as saying, ‘I called the infectious disease team; they're going to come see the patient,’” she said. “They have to ask me, ‘How do I call the infectious disease team? How do I know which private office to call?’”

But since not every graduate will become an academic physician, being exposed to the differences between the two types of hospitals can better inform them about career options after training, Dr. Sundar noted. “Also, when we started it, we thought we could use this as a recruitment tool if anybody comes and does the elective and loves our hospital and wants to apply for a job.”

Varying challenges

In the survey study, the most common barrier identified by programs without a hospitalist rotation was lack of a well-defined model. But while building an elective from the ground up is a challenge, it's doable, said study lead author Steven Ludwin, MD, ACP Member, an associate professor of medicine at the University of California, San Francisco, which established its own elective in 2014.

“A number of places kind of build it from scratch,” he said. “I think that is a little bit of a challenge, but certainly not insurmountable because the imprint is typically a two- to four-week rotation, which can be built out based on local needs and interest.”

Other difficulties vary by institution. For Dr. Sankey, a challenge at the outset was the need to bridge leadership between the hospital and the medical school. “I had two sets of siloed hierarchies that I needed to pitch this to and get buy-in from. . . . The most intensive input of time is right up front, right in the beginning when you're designing it, when you're implementing it.”

At Emory Saint Joseph's, the biggest challenge is scheduling the residents, said Dr. Sundar, adding that she asks for three months' notice. And since the residents have to schedule their elective time in certain months, patient volume varies and can affect their experience, she said.

“We don't have patient caps, so if you have the residents come during the busier winter months, it can be a little bit challenging to get that experience and make it the best it can be if there's a very high census,” Dr. Sundar said.

Dr. Sweigart, the University of Kentucky hospitalist, said that finding a way to fit the track into the existing residency program structure was his biggest challenge. At his program, this takes the form of one noon conference a month where residents in the track are excused from the regular residency conference and come to a hospitalist session instead.

“That requires a lot of support from program leadership, obviously,” he said. “But once you find a way that it fits, then it's just about selecting the most high-yield content that you can to cram into that space and then slowly expanding.” One effective way to sell the track to the broader residency program was to share the best content with all residents, who can appreciate guidance on, say, cover letters and contract negotiation, Dr. Sweigart noted.

In the survey study, one challenge reported by 15% of the program leaders without hospitalist rotations was low faculty interest. But directors of hospitalist electives and tracks have found the opposite: People are generally happy to help. “Current hospitalists who have sort of struggled to learn these things in a learn-as-you-go format are really happy to share some of this wisdom,” said Dr. Sweigart.

While creating the elective at Yale, Dr. Sankey reached out to other hospitalists around the country to get a feel for their curricula. As expected, there was substantial variability. “All of the electives are homegrown, and I just thought, ‘Wouldn't it be cool if there was some way for us to cross-pollinate, to share experiences and ideas?’”

Given the heterogeneity and lack of an established standard, Dr. Sankey and others are working with the Society of Hospital Medicine and the Society of General Internal Medicine to create an accessible and searchable database of hospital medicine electives and how they are structured. His goal is for the website to be up and running in 2019.

“This will hopefully be a really powerful, really useful way in which we can enhance and innovate in terms of how we offer this kind of elective material for medical trainees,” Dr. Sankey said.