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An agenda for hospitalists' research

The pandemic added opportunities and barriers to an already challenged field.

The experiences of ACP Member Ernest Fischer, MD, highlight common challenges facing researchers in hospital medicine, both before and during a pandemic.

As a young hospitalist interested in conducting research, he knew it was important to have a mentor, but none readily presented themselves. So Dr. Fischer, an associate professor at Georgetown University in Washington, D.C., identified a hospitalist investigator at another institution who appeared to have similar interests.

“One day, I just cold emailed him,” he said. “I've since then been able to email him every now and then to bounce some ideas off about [study] design.”

By early 2020, Dr. Fischer and a local colleague were ready to launch a study on the use of point-of-care ultrasound (POCUS) in heart failure. They had submitted their plan to the institutional review board and had several hospitalists who had recently completed a POCUS boot camp training program ready to participate.

Then the pandemic hit. Along with so much else, the planned study “got completely submerged by COVID,” said Dr. Fischer. “So we shifted gears to looking at COVID [and] jumped into a project looking at ultrasound for COVID.”

But other researchers had the same idea, so they had to pivot their focus away from diagnosis. “That was the kind of unusual challenge about COVID research, having to find something that you can feel confident nobody else has just done or is working on at the same time,” Dr. Fischer said.

The crowding in the field also made it more challenging to get published. “The appetite for COVID research changed quite a bit after the first few months,” he said. But success came when their study on the prognostic value of POCUS for lung ultrasound in COVID-19 was published by the Journal of Intensive Care Medicine in February.

Given the obstacles along the way, it's understandable that a recent survey of academic hospital medicine groups found their median number of clinician investigators to be zero.

The survey collected responses from 43 groups representing 2,503 hospitalists and found a total of 79 clinician investigators, far from evenly distributed. Two hospital medicine groups reported having 12 clinician investigators at their respective institutions, while 22 had none. The survey was conducted through the Hospital Medicine Reengineering Network (HOMERuN), a hospital medicine research collaborative that facilitates and conducts multisite research studies.

That means the results probably actually overestimated researchers' presence in academic hospital medicine, said the authors, who subtitled their findings with “a call to action” when they were published by the Journal of Hospital Medicine on Feb. 17. Their conclusion attributed the “dearth of hospitalist clinician investigators” at least in part to lack of resources for research.

“In order to be successful in research, you not only need mentorship, but you need resources, like basic biostatistical support, and then you need training,” said Shoshana Herzig, MD, MPH, FACP, a study coauthor and an associate professor at Harvard Medical School in Boston. She and others recently offered ACP Hospitalist their thoughts on why it's important for more hospitalists to overcome these barriers and conduct research, as well as how the pandemic has affected these efforts.

Pre-existing problems

“The unique perspective of hospitalists really situates them well to do good research,” said Valerie Vaughn, MD, MSc, FACP, an assistant professor at the University of Utah in Salt Lake City. “There are a lot of hospitalists that I've worked with who have great ideas and great ways of improving care that would be difficult to know if you weren't right up in the mix taking care of people.”

Fewer of them have the connections and know-how to get those ideas all the way to publication, however. “You really do need dedicated training in methods and so forth in order to be competitive for grant funding. It's not just something that you can intuitively figure out,” said Anna Maw, MD, an assistant professor at the University of Colorado in Denver.

Most subspecialists who want to go into research get that training during fellowship, she said. Although such fellowships do also exist in general internal medicine, there's a catch, Dr. Herzig noted. “Unfortunately, most of those existing fellowships are really geared toward primary care doctors rather than hospital medicine physicians, so most hospitalists don't have a way to actually get the training necessary,” she said.

Research fellowships specifically for hospitalists are “few and far between and not well promoted,” Dr. Herzig said. One could perhaps describe hospitalist researchers the same way. “Because young hospitalists don't see a lot of role models who are investigators, it isn't as well established as a career path for them,” she said.

Even if they wanted to try, they'd likely run into resource problems. For example, 56.1% of the respondents to the HOMERuN survey reported not having any research assistants for their hospital medicine programs. The grants that could potentially cover these expenses are tough to get, the experts agreed.

“Federal funding has been very competitive for the last 20 years,” said Dr. Maw. “It's difficult to establish yourself and even just maintain once you are established. Most of the successful researchers I know, they work literally all the time.”

Hospitals could provide funding, and there's a good case for them to do that, according to David Schwartz, MD, MPH, FACP, a professor of pulmonary sciences and critical care at the University of Colorado.

“Usually, for every dollar you invest [in research], you get $10 back in terms of new devices, improvements in health care, and reductions in disease,” he said. But Dr. Schwartz sees the other side too. “Investigators are an expensive commodity in medical centers. . . . They have a lot of uncertainty in terms of what their research is going to show.”

Pandemic paradoxes

As Dr. Fischer's research experience revealed, the pandemic only heightened many existing uncertainties and challenges.

Pandemic-related effects on academic medical centers' profit margins, which were down more than 25% even including support from the CARES Act, led to reduced funding for emerging and established scientists, according to a paper published by the American Journal of Respiratory and Critical Care Medicine on Feb. 17. The authors, including Dr. Schwartz, called for reinvesting in researchers.

Recent scientific progress shows the value of such investment, Dr. Schwartz said. “What has led us out of this pandemic? If it's not the science of social distancing, it was the science of what treatments work and don't work . . . and clearly the development of vaccines,” he said. “Hospitals reap the benefits of delivering state-of-the-art care, and state-of-the-art care is only possible if you have a vibrant, successful research environment.”

The effects of COVID-19 on the research environment for hospitalists have varied widely. When the pandemic first hit, those who are usually investigators dropped that work. “All of the researchers, at least in the division here, myself included, who had time to be able to respond were pulled to do clinical duty,” said Vineet Chopra, MBBS, FACP, a professor of medicine at the University of Michigan in Ann Arbor. “Our research stopped.”

For some hospitalists whose usual focus was clinical care, however, day-to-day practice actually seemed more conducive to research. “If you were observing patterns or seeing trends this spring taking care of patients with COVID, then you have hypotheses that developed,” said Benjamin Galen, MD, FACP, an associate professor at Albert Einstein College of Medicine and Montefiore Medical Center in New York. “Noticing that some patients benefited from steroids or some seemed to have clots . . . brought people into research.” Dr. Galen coauthored a study of deep venous thromboembolism in COVID-19 that was published in June 2020 by the Journal of Vascular Surgery: Venous and Lymphatic Disorders.

The urgent need to test interventions also created opportunities for clinical hospitalists to participate in research, he said. “I got involved in a trial of anticoagulation for COVID, which was at 100 different sites across the country.”

The relationships required for research faced a similar paradox. On one hand, mentoring fell fully off most hospitalist investigators' priority lists last spring. “I had eight to 10 mentees who were writing their K01 [award applications], who were doing a number of really important things,” said Dr. Chopra. “But in the first few months, it was ‘cancel everything,’ so I feel like their careers are probably going to be stunted.”

On the other hand, some clinicians forged new relationships with researchers. “I was a collaborator with some of the basic-science people at my institution, enrolling subjects and just getting swabs and blood samples from patients with COVID. Those relationships you have or build don't go away,” said Dr. Galen.

While the need to socially distance was a major hurdle to some aspects of research and froze many clinical trials in their tracks, it also had a potential silver lining, according to Dr. Vaughn. “In the past we'd have these lab meetings, and it's hard to get everybody on the same campus,” she said. “Having more of these remote meetings will allow for more collaboration, even within the same institution, but across institutions—even internationally.”

Of course, remote life also created huge hurdles, especially for investigators who are also parents. “How do you take care of kids who are out of school and go into a lab every day? I know a lot of people who had really profound setbacks in their work,” said Dr. Vaughn.

Growing the field

How, in light of these challenges, can hospital medicine expand the ranks of its researchers? Experts have several ideas.

“Structured and formalized mentorship is an essential part of the development of clinician investigators in hospital medicine,” advised the authors of the Journal of Hospital Medicine article.

That is a burden, albeit a necessary one, on the existing investigators, noted Dr. Herzig. “Because there are so few of us, we're all stretched incredibly thin,” she said. “Without continuing to stretch yourself thin and doing that for the next generation, we're just going to perpetuate the problem.”

Ideally, the role modeling and support would extend beyond younger hospitalists and trainees to include medical students, said Dr. Schwartz. “If students want to come into our labs, we should make our labs available and accessible to students, even if they have very little experience doing research. Our obligation really is not only to do the research, but to teach others how to do the research and to get others excited about doing research,” he said.

Successful researchers can also help others get into a position to get paid to do research, the experts said. Hospitalist investigators should not only mentor but sponsor their juniors, recommended Shaker Eid, MD, an associate professor at Johns Hopkins University in Baltimore.

“Sponsorship is actually being an advocate for that person in academic and research circles,” he said. “If I end up being on a review board for a study or one of the committees at the NIH or the CDC, I would want to sponsor somebody who's a hospitalist so when my term is done, that person is equipped to be on that committee as well.”

Actively working to advance fellow hospitalists' careers in this manner could make it easier for others in the specialty to obtain research funding, Dr. Eid said. “A lot of the people who are reviewing those grants are subspecialists,” he said. “Start including more hospitalists reviewing those grants, and hopefully those people will vouch for those who have not gone through the [subspecialty] training.”

Teaming up was another common recommendation. “We need to encourage more groups of investigators working together on big projects, on big ideas, on big problems,” said Dr. Schwartz. “If we were to work more collaboratively with each other, we would be able to achieve much more as a group.”

That's an area where organizations that represent hospitalists, like ACP or the Society of Hospital Medicine, could facilitate research, suggested Dr. Chopra. “Put out a hospitalist-focused series of questions, a research agenda, with funding, without funding,” he said. “Galvanize a lot of us across the country to swim in the same lane.”

Perhaps the pandemic's ongoing challenges and opportunities could lead to a golden age for hospitalist investigators. “The metaphor I've heard commonly for some of the older generation is HIV in the '80s,” Dr. Chopra said. “It was their moment of glory. They'll never go through something like that again. I feel very much the same way.”