If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• To describe the correlation between inpatient and outpatient blood pressure measurements.

• To assess the potential benefits of prescribing antihypertensive medication in hospitalized patients with hypertension.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• To describe the correlation between inpatient and outpatient blood pressure measurements.

• To assess the potential benefits of prescribing antihypertensive medication in hospitalized patients with hypertension.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

If you wish to receive credit for this activity, please refer to the website: www.wileyblackwellcme.com.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

The objectives need to be changed. Please remove the existing ones, and include these two:

• To describe the correlation between inpatient and outpatient blood pressure measurements.

• To assess the potential benefits of prescribing antihypertensive medication in hospitalized patients with hypertension.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Journal of Hospital Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Journal of Hospital Medicine is single‐blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. The primary resolution method used was peer review and review by a non‐conflicted expert.

Instructions on Receiving Credit

For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication.

Follow these steps to earn credit:

• Log on to www.wileyblackwellcme.com

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Providing family centered care has been identified as a goal in the Institute of Medicine's report Crossing the Quality Chiasm1 and endorsed by the American Academy of Pediatrics.2 Traditionally, rounds are the central organizing structure for clinical work, decision making, and teaching in the inpatient setting. Patient care and educational goals emanate from rounds. Over the past several decades rounds have migrated from the patient's bedside to the privacy of the conference room. In our experience, although conference room rounds offer some advantages, patients and families are not privy to the data or decision‐making process used to determine their diagnosis and plan of care. The ritual that frequently occurs after conference‐room rounds is that the team members (medical students, residents, nurses, attending) visit the patient and family independently throughout the course of the day, communicating their understanding of medical and affective issues in a manner that families often view as providing confusing, if not contradictory information.

Conducting rounds entirely at the bedside can bypass this systemic flaw, allowing parents and patients to correct inaccurate data, and enable them to make their values and concerns known to the team. This model can help to connect the caregivers and receivers of care, and represents a collaborative communication process, the foundation for effective family‐centered rounds (FCR). When team members discuss how they interpret clinical data in the presence of the family it helps them to understand how and why a management plan is conceived. The care team develops an alliance of trust with the family through this transparent communication and joint decision‐making.

Despite the potential for enhancing patient/family satisfaction and endorsements by public and professional organizations, in a recent study less than half of pediatric hospitalists reported conducting FCR.3 Trainees and attending physicians raised concerns about the potential for FCR to waste time and diminish teaching.4 Trainees' perceptions of the educational value of FCR has not been well studied, but a recent qualitative study of pediatric residents reported that if conducted well, FCRs enhance education and clinical skills by increasing the number of patients seen by each team member, and by offering opportunities to improve physical examination skills. Trainees appreciated role‐modeling and realtime feedback by attending physicians. Senior residents reported enhanced leadership and teaching opportunities.5

The aim of this study was to design and implement a faculty development program to address the need of our junior hospitalist faculty members to enhance teaching during FCR.

Methods

We determined, based upon direct observation, a focus group and survey feedback from our pediatric residents, that for inpatient teaching during FCR to be successful, our faculty needed training in the following areas: orienting learners, providing feedback, teaching assessment of key physical exam findings, correcting errors in clinical reasoning, and promoting the role of the senior resident as team leader. We developed the Observed Structured Teaching Exercises (OSTE)6 and related workshops to promote key behaviors identified from the literature for each of the areas.

All of the Children's National Medical Center (CNMC) Pediatric hospitalists (N = 14) who were not investigators in the study were asked to participate. They were informed of the study design and the overall goal of making inpatient rounds more effective and efficient through better teaching skills. The study was approved by the CNMC institutional review board and was conducted from August to September 2007 in the CLASS (Clinical Learning and Simulation Skills) at The George Washington University School of Medicine and Health Sciences.

To assess faculty and fellow baseline knowledge and skills, the authors conducted a preintervention OSTE consisting of 4 stations: 1) physical exam interpretation and promoting PL‐3 autonomy (Established Patient), 2) stimulating clinical reasoning (New Patient), 3) feedback, and 4) facilitating an orientation. This exercise was followed within 2 weeks by four 90‐minute interactive workshops that focused on the topic areas as evaluated in the OSTEs. Each workshop consisted of a brief evidence‐based didactic component, interactive discussion, and skill building exercises to practice desired teaching behaviors. Two weeks following the workshops, the group participated in postintervention OSTEs similar to the preintervention scenarios, with minor changes, such as presenting diagnoses, to avoid pattern recognition.

Results

All 14 eligible hospitalists voluntarily participated. Their mean year postcompletion of residency training for the faculty was 17 months 14 months; 71% were female. None of the participants experienced previous training in the areas proposed in the study.

Participants assigned high scores to the quality of the workshops, the OSTE experience and their learning from the participating in the faculty development exercise. The differences between pre‐ and post‐OSTE scenario as well as overall scores for the 4 stations were statistically significant (P < .0001). Particular improvements were noted in the correction of incorrect new admission diagnoses (56% pre, 86% post) and orientation (65% pre, 95% post; see Table 2).

Discussion

If FCR are to be universally adopted in the academic pediatric inpatient setting, faculty must successfully balance the educational needs of trainees as well as efficiently negotiating a plan of management with patients and families. The ability of faculty to consistently orchestrate rounds so that they meet educational needs of varied levels of learners, while ensuring that patient management is correct and well communicated to families is a very complex task.

We found using OSTEs to frame desired behavior, supplemented with background information to validate the desired behaviors followed by deliberate practice opportunities during the workshops to be an effective faculty development strategy. We not only provided participants with feedback on the group's performance according to the rating scale, but also gave them the opportunity to practice rating each other using the scale so that they could reflect on the elements of their performance that merited a specific rating.

This strategy for training faculty to perform well in the complex environment within the patient's room during FCR is similar in some respects with training military personnel for complex battle situations.15 Desired behaviors are broken down and packaged within a framework to be implemented in a specific context. For example, we combined aspects of the One Minute Preceptor model (OMP)12 with Bordage's Problem Representation model to create a framework of behaviors to promote and correct errors in clinical reasoning.16, 17 Another framework was created and practiced to promote assessment of the physical exam at the bedside. Orientation and feedback, although not frequently used components of actual FCR, are necessary to set expectations and calibrate learner's performance during FCR.

The OSTE is an observed examination that has been validated for evaluating the teaching skills of faculty and residents.18 We planned to use learner‐centered, interactive workshops as the key component of the training intervention with the pre‐ and posttest OSTE as a measure of their effectiveness. However, we found in faculty feedback that the OSTEs were actually a key adjuvant, to the workshop training in that they provided a major source of feedback and learning opportunities in addition to their inherent evaluative qualities.

Each of 4 workshops was designed to teach participants the behaviors assessed in the 4 OSTE stations. The pretest OSTE provided a baseline for participant performance and served to activate the participants to focus on key teaching behaviors during the workshop. During the workshop following the pretest OSTE, participants were given copies of the rating scales and feedback on the performance of the group as a whole on each rated behavior. The evidence used to create the rating instruments was presented and participants had the opportunity to debate and agree on the instrument's construct validity. They then had the opportunity to engage in deliberate practice during role plays depicting challenges to orienting a learner, providing feedback, and to family centered rounds. The posttest OSTE served as summative evaluation of the participants' ability to perform the practiced behaviors effectively in a simulated teaching environment.

We chose to focus the FCR scenarios on correcting mistakes in clinical reasoning for a new patient and on teaching key parts of the physical exam during rounds for an established patient. Errors in clinical reasoning lead to misdirected patient management and are the number 1 cause of medical errors.19, 20 Bedside rounds are a perfect venue for reinforcing and fine‐tuning diagnostic reasoning because all the crucial sources of data are present: the patient, the parent, the nurse, and the computer with lab and imaging results. Faculty members and trainees have both expressed discomfort at correcting errors in clinical reasoning in front of families, leading to missed learning opportunities.21

During the workshop on clinical reasoning, we taught faculty how to use the Problem Representation method to analyze and correct errors in clinical reasoning. The method, studied by Bordage and associates22 forces learners to identify the key features of a presentation and relate their interpretation of the findings by using semantic qualifiers. We trained faculty to deliberately listen for the learner's interpretation of the key features to determine how a misdiagnosis occurred. They were also trained to walk trainees back through their thought process in an objective way, correcting the misinterpretation of data, so that the trainee's competence is not compromised in the eyes of the team or the parents. Teaching the trainee to think correctly about a clinical problem benefits the other members of the team, as well as providing the parents with a better understanding of the rationale for the management plan.

Correct interpretation of the physical exam findings is crucial to making the correct diagnosis. However, there have been several articles chronicling the lost art of eliciting and interpreting physical exam findings, ranging from the cardiac exam to neurological exam.23 A minority of physical exam teaching occurs at the patient's bedside, partly attributed to faculty members discomfort with this type of teaching.24, 25 To enhance the comfort of our faculty members, we included behaviors referenced in articles on teaching a skill,26 activated demonstration,10 and effective bedside teaching27 to guide faculty to incorporate eliciting and interpreting focused aspects of the physical exam during rounds.

Our FCR evaluation templates awarded the highest scores if the hospitalist encouraged senior residents to model clinical reasoning or physical exam skills for junior learners. Hospitalists' presence, especially on work rounds, can diminish the senior resident's opportunity to gain experience and confidence in leading the team.28 We therefore explicitly directed hospitalists to promote the role of the senior resident as the team leader during workshops, while priming faculty to assume the role of educational coach.29

We hypothesize that several factors contributed to the success of the OSTE workshopOSTE intervention. First, faculty members willingly volunteered to participate because they recognized gaps in their own knowledge and skill at leading FCR. They found the ability to deliberately practice the desired behaviors in the OSTE exercises to be the most useful part of the exercise, because the scenarios were authentic and SLs were real trainees.

Although we included all the junior faculty members of our large Pediatric Hospitalist Division in our study, our sample size is still small; limiting our ability to generalize our findings. We found the scheduling of 14 hospitalists to attend 4 different events in close succession to be problematic. Conducting the OSTE sessions at the GW CLASS center 5 miles away from our hospital was also logistically challenging.

We plan to simplify the logistics so that we can incorporate this model in the training of new hospitalists in the division. We still plan to use preintervention FCR OSTEs, but instead of workshops, will provide background information by means of self‐directed Web‐based modules. We will also videotape the OSTEs and provide faculty with a template to rate their own performance and then compare it with ratings from SLs. This individualized feedback and self‐reflection could result in better performance30 than the summary group feedback we gave during the workshops.

Another limitation of this study is the lack of data regarding the consistency of our faculty participants' performance in real FCR. Finally, we did not study the impact of the desired behaviors on patient, trainee, or nursing satisfaction, learning, or efficiency.

Conclusion

In conclusion, we found incorporating OSTEs into a faculty development program to improve FCR to be an effective strategy for changing faculty behavior in leading FCR. Additional study is needed to determine if replacing the workshops with Web‐based tutorials is equally effective and to determine if this faculty development strategy results in long‐term consistent practice in conducting rounds in real inpatient settings.

Providing family centered care has been identified as a goal in the Institute of Medicine's report Crossing the Quality Chiasm1 and endorsed by the American Academy of Pediatrics.2 Traditionally, rounds are the central organizing structure for clinical work, decision making, and teaching in the inpatient setting. Patient care and educational goals emanate from rounds. Over the past several decades rounds have migrated from the patient's bedside to the privacy of the conference room. In our experience, although conference room rounds offer some advantages, patients and families are not privy to the data or decision‐making process used to determine their diagnosis and plan of care. The ritual that frequently occurs after conference‐room rounds is that the team members (medical students, residents, nurses, attending) visit the patient and family independently throughout the course of the day, communicating their understanding of medical and affective issues in a manner that families often view as providing confusing, if not contradictory information.

Conducting rounds entirely at the bedside can bypass this systemic flaw, allowing parents and patients to correct inaccurate data, and enable them to make their values and concerns known to the team. This model can help to connect the caregivers and receivers of care, and represents a collaborative communication process, the foundation for effective family‐centered rounds (FCR). When team members discuss how they interpret clinical data in the presence of the family it helps them to understand how and why a management plan is conceived. The care team develops an alliance of trust with the family through this transparent communication and joint decision‐making.

Despite the potential for enhancing patient/family satisfaction and endorsements by public and professional organizations, in a recent study less than half of pediatric hospitalists reported conducting FCR.3 Trainees and attending physicians raised concerns about the potential for FCR to waste time and diminish teaching.4 Trainees' perceptions of the educational value of FCR has not been well studied, but a recent qualitative study of pediatric residents reported that if conducted well, FCRs enhance education and clinical skills by increasing the number of patients seen by each team member, and by offering opportunities to improve physical examination skills. Trainees appreciated role‐modeling and realtime feedback by attending physicians. Senior residents reported enhanced leadership and teaching opportunities.5

The aim of this study was to design and implement a faculty development program to address the need of our junior hospitalist faculty members to enhance teaching during FCR.

Methods

We determined, based upon direct observation, a focus group and survey feedback from our pediatric residents, that for inpatient teaching during FCR to be successful, our faculty needed training in the following areas: orienting learners, providing feedback, teaching assessment of key physical exam findings, correcting errors in clinical reasoning, and promoting the role of the senior resident as team leader. We developed the Observed Structured Teaching Exercises (OSTE)6 and related workshops to promote key behaviors identified from the literature for each of the areas.

All of the Children's National Medical Center (CNMC) Pediatric hospitalists (N = 14) who were not investigators in the study were asked to participate. They were informed of the study design and the overall goal of making inpatient rounds more effective and efficient through better teaching skills. The study was approved by the CNMC institutional review board and was conducted from August to September 2007 in the CLASS (Clinical Learning and Simulation Skills) at The George Washington University School of Medicine and Health Sciences.

To assess faculty and fellow baseline knowledge and skills, the authors conducted a preintervention OSTE consisting of 4 stations: 1) physical exam interpretation and promoting PL‐3 autonomy (Established Patient), 2) stimulating clinical reasoning (New Patient), 3) feedback, and 4) facilitating an orientation. This exercise was followed within 2 weeks by four 90‐minute interactive workshops that focused on the topic areas as evaluated in the OSTEs. Each workshop consisted of a brief evidence‐based didactic component, interactive discussion, and skill building exercises to practice desired teaching behaviors. Two weeks following the workshops, the group participated in postintervention OSTEs similar to the preintervention scenarios, with minor changes, such as presenting diagnoses, to avoid pattern recognition.

Results

All 14 eligible hospitalists voluntarily participated. Their mean year postcompletion of residency training for the faculty was 17 months 14 months; 71% were female. None of the participants experienced previous training in the areas proposed in the study.

Participants assigned high scores to the quality of the workshops, the OSTE experience and their learning from the participating in the faculty development exercise. The differences between pre‐ and post‐OSTE scenario as well as overall scores for the 4 stations were statistically significant (P < .0001). Particular improvements were noted in the correction of incorrect new admission diagnoses (56% pre, 86% post) and orientation (65% pre, 95% post; see Table 2).

Discussion

If FCR are to be universally adopted in the academic pediatric inpatient setting, faculty must successfully balance the educational needs of trainees as well as efficiently negotiating a plan of management with patients and families. The ability of faculty to consistently orchestrate rounds so that they meet educational needs of varied levels of learners, while ensuring that patient management is correct and well communicated to families is a very complex task.

We found using OSTEs to frame desired behavior, supplemented with background information to validate the desired behaviors followed by deliberate practice opportunities during the workshops to be an effective faculty development strategy. We not only provided participants with feedback on the group's performance according to the rating scale, but also gave them the opportunity to practice rating each other using the scale so that they could reflect on the elements of their performance that merited a specific rating.

This strategy for training faculty to perform well in the complex environment within the patient's room during FCR is similar in some respects with training military personnel for complex battle situations.15 Desired behaviors are broken down and packaged within a framework to be implemented in a specific context. For example, we combined aspects of the One Minute Preceptor model (OMP)12 with Bordage's Problem Representation model to create a framework of behaviors to promote and correct errors in clinical reasoning.16, 17 Another framework was created and practiced to promote assessment of the physical exam at the bedside. Orientation and feedback, although not frequently used components of actual FCR, are necessary to set expectations and calibrate learner's performance during FCR.

The OSTE is an observed examination that has been validated for evaluating the teaching skills of faculty and residents.18 We planned to use learner‐centered, interactive workshops as the key component of the training intervention with the pre‐ and posttest OSTE as a measure of their effectiveness. However, we found in faculty feedback that the OSTEs were actually a key adjuvant, to the workshop training in that they provided a major source of feedback and learning opportunities in addition to their inherent evaluative qualities.

Each of 4 workshops was designed to teach participants the behaviors assessed in the 4 OSTE stations. The pretest OSTE provided a baseline for participant performance and served to activate the participants to focus on key teaching behaviors during the workshop. During the workshop following the pretest OSTE, participants were given copies of the rating scales and feedback on the performance of the group as a whole on each rated behavior. The evidence used to create the rating instruments was presented and participants had the opportunity to debate and agree on the instrument's construct validity. They then had the opportunity to engage in deliberate practice during role plays depicting challenges to orienting a learner, providing feedback, and to family centered rounds. The posttest OSTE served as summative evaluation of the participants' ability to perform the practiced behaviors effectively in a simulated teaching environment.

We chose to focus the FCR scenarios on correcting mistakes in clinical reasoning for a new patient and on teaching key parts of the physical exam during rounds for an established patient. Errors in clinical reasoning lead to misdirected patient management and are the number 1 cause of medical errors.19, 20 Bedside rounds are a perfect venue for reinforcing and fine‐tuning diagnostic reasoning because all the crucial sources of data are present: the patient, the parent, the nurse, and the computer with lab and imaging results. Faculty members and trainees have both expressed discomfort at correcting errors in clinical reasoning in front of families, leading to missed learning opportunities.21

During the workshop on clinical reasoning, we taught faculty how to use the Problem Representation method to analyze and correct errors in clinical reasoning. The method, studied by Bordage and associates22 forces learners to identify the key features of a presentation and relate their interpretation of the findings by using semantic qualifiers. We trained faculty to deliberately listen for the learner's interpretation of the key features to determine how a misdiagnosis occurred. They were also trained to walk trainees back through their thought process in an objective way, correcting the misinterpretation of data, so that the trainee's competence is not compromised in the eyes of the team or the parents. Teaching the trainee to think correctly about a clinical problem benefits the other members of the team, as well as providing the parents with a better understanding of the rationale for the management plan.

Correct interpretation of the physical exam findings is crucial to making the correct diagnosis. However, there have been several articles chronicling the lost art of eliciting and interpreting physical exam findings, ranging from the cardiac exam to neurological exam.23 A minority of physical exam teaching occurs at the patient's bedside, partly attributed to faculty members discomfort with this type of teaching.24, 25 To enhance the comfort of our faculty members, we included behaviors referenced in articles on teaching a skill,26 activated demonstration,10 and effective bedside teaching27 to guide faculty to incorporate eliciting and interpreting focused aspects of the physical exam during rounds.

Our FCR evaluation templates awarded the highest scores if the hospitalist encouraged senior residents to model clinical reasoning or physical exam skills for junior learners. Hospitalists' presence, especially on work rounds, can diminish the senior resident's opportunity to gain experience and confidence in leading the team.28 We therefore explicitly directed hospitalists to promote the role of the senior resident as the team leader during workshops, while priming faculty to assume the role of educational coach.29

We hypothesize that several factors contributed to the success of the OSTE workshopOSTE intervention. First, faculty members willingly volunteered to participate because they recognized gaps in their own knowledge and skill at leading FCR. They found the ability to deliberately practice the desired behaviors in the OSTE exercises to be the most useful part of the exercise, because the scenarios were authentic and SLs were real trainees.

Although we included all the junior faculty members of our large Pediatric Hospitalist Division in our study, our sample size is still small; limiting our ability to generalize our findings. We found the scheduling of 14 hospitalists to attend 4 different events in close succession to be problematic. Conducting the OSTE sessions at the GW CLASS center 5 miles away from our hospital was also logistically challenging.

We plan to simplify the logistics so that we can incorporate this model in the training of new hospitalists in the division. We still plan to use preintervention FCR OSTEs, but instead of workshops, will provide background information by means of self‐directed Web‐based modules. We will also videotape the OSTEs and provide faculty with a template to rate their own performance and then compare it with ratings from SLs. This individualized feedback and self‐reflection could result in better performance30 than the summary group feedback we gave during the workshops.

Another limitation of this study is the lack of data regarding the consistency of our faculty participants' performance in real FCR. Finally, we did not study the impact of the desired behaviors on patient, trainee, or nursing satisfaction, learning, or efficiency.

Conclusion

In conclusion, we found incorporating OSTEs into a faculty development program to improve FCR to be an effective strategy for changing faculty behavior in leading FCR. Additional study is needed to determine if replacing the workshops with Web‐based tutorials is equally effective and to determine if this faculty development strategy results in long‐term consistent practice in conducting rounds in real inpatient settings.

Providing family centered care has been identified as a goal in the Institute of Medicine's report Crossing the Quality Chiasm1 and endorsed by the American Academy of Pediatrics.2 Traditionally, rounds are the central organizing structure for clinical work, decision making, and teaching in the inpatient setting. Patient care and educational goals emanate from rounds. Over the past several decades rounds have migrated from the patient's bedside to the privacy of the conference room. In our experience, although conference room rounds offer some advantages, patients and families are not privy to the data or decision‐making process used to determine their diagnosis and plan of care. The ritual that frequently occurs after conference‐room rounds is that the team members (medical students, residents, nurses, attending) visit the patient and family independently throughout the course of the day, communicating their understanding of medical and affective issues in a manner that families often view as providing confusing, if not contradictory information.

Conducting rounds entirely at the bedside can bypass this systemic flaw, allowing parents and patients to correct inaccurate data, and enable them to make their values and concerns known to the team. This model can help to connect the caregivers and receivers of care, and represents a collaborative communication process, the foundation for effective family‐centered rounds (FCR). When team members discuss how they interpret clinical data in the presence of the family it helps them to understand how and why a management plan is conceived. The care team develops an alliance of trust with the family through this transparent communication and joint decision‐making.

Despite the potential for enhancing patient/family satisfaction and endorsements by public and professional organizations, in a recent study less than half of pediatric hospitalists reported conducting FCR.3 Trainees and attending physicians raised concerns about the potential for FCR to waste time and diminish teaching.4 Trainees' perceptions of the educational value of FCR has not been well studied, but a recent qualitative study of pediatric residents reported that if conducted well, FCRs enhance education and clinical skills by increasing the number of patients seen by each team member, and by offering opportunities to improve physical examination skills. Trainees appreciated role‐modeling and realtime feedback by attending physicians. Senior residents reported enhanced leadership and teaching opportunities.5

The aim of this study was to design and implement a faculty development program to address the need of our junior hospitalist faculty members to enhance teaching during FCR.

Methods

We determined, based upon direct observation, a focus group and survey feedback from our pediatric residents, that for inpatient teaching during FCR to be successful, our faculty needed training in the following areas: orienting learners, providing feedback, teaching assessment of key physical exam findings, correcting errors in clinical reasoning, and promoting the role of the senior resident as team leader. We developed the Observed Structured Teaching Exercises (OSTE)6 and related workshops to promote key behaviors identified from the literature for each of the areas.

All of the Children's National Medical Center (CNMC) Pediatric hospitalists (N = 14) who were not investigators in the study were asked to participate. They were informed of the study design and the overall goal of making inpatient rounds more effective and efficient through better teaching skills. The study was approved by the CNMC institutional review board and was conducted from August to September 2007 in the CLASS (Clinical Learning and Simulation Skills) at The George Washington University School of Medicine and Health Sciences.

To assess faculty and fellow baseline knowledge and skills, the authors conducted a preintervention OSTE consisting of 4 stations: 1) physical exam interpretation and promoting PL‐3 autonomy (Established Patient), 2) stimulating clinical reasoning (New Patient), 3) feedback, and 4) facilitating an orientation. This exercise was followed within 2 weeks by four 90‐minute interactive workshops that focused on the topic areas as evaluated in the OSTEs. Each workshop consisted of a brief evidence‐based didactic component, interactive discussion, and skill building exercises to practice desired teaching behaviors. Two weeks following the workshops, the group participated in postintervention OSTEs similar to the preintervention scenarios, with minor changes, such as presenting diagnoses, to avoid pattern recognition.

Results

All 14 eligible hospitalists voluntarily participated. Their mean year postcompletion of residency training for the faculty was 17 months 14 months; 71% were female. None of the participants experienced previous training in the areas proposed in the study.

Participants assigned high scores to the quality of the workshops, the OSTE experience and their learning from the participating in the faculty development exercise. The differences between pre‐ and post‐OSTE scenario as well as overall scores for the 4 stations were statistically significant (P < .0001). Particular improvements were noted in the correction of incorrect new admission diagnoses (56% pre, 86% post) and orientation (65% pre, 95% post; see Table 2).

Discussion

If FCR are to be universally adopted in the academic pediatric inpatient setting, faculty must successfully balance the educational needs of trainees as well as efficiently negotiating a plan of management with patients and families. The ability of faculty to consistently orchestrate rounds so that they meet educational needs of varied levels of learners, while ensuring that patient management is correct and well communicated to families is a very complex task.

We found using OSTEs to frame desired behavior, supplemented with background information to validate the desired behaviors followed by deliberate practice opportunities during the workshops to be an effective faculty development strategy. We not only provided participants with feedback on the group's performance according to the rating scale, but also gave them the opportunity to practice rating each other using the scale so that they could reflect on the elements of their performance that merited a specific rating.

This strategy for training faculty to perform well in the complex environment within the patient's room during FCR is similar in some respects with training military personnel for complex battle situations.15 Desired behaviors are broken down and packaged within a framework to be implemented in a specific context. For example, we combined aspects of the One Minute Preceptor model (OMP)12 with Bordage's Problem Representation model to create a framework of behaviors to promote and correct errors in clinical reasoning.16, 17 Another framework was created and practiced to promote assessment of the physical exam at the bedside. Orientation and feedback, although not frequently used components of actual FCR, are necessary to set expectations and calibrate learner's performance during FCR.

The OSTE is an observed examination that has been validated for evaluating the teaching skills of faculty and residents.18 We planned to use learner‐centered, interactive workshops as the key component of the training intervention with the pre‐ and posttest OSTE as a measure of their effectiveness. However, we found in faculty feedback that the OSTEs were actually a key adjuvant, to the workshop training in that they provided a major source of feedback and learning opportunities in addition to their inherent evaluative qualities.

Each of 4 workshops was designed to teach participants the behaviors assessed in the 4 OSTE stations. The pretest OSTE provided a baseline for participant performance and served to activate the participants to focus on key teaching behaviors during the workshop. During the workshop following the pretest OSTE, participants were given copies of the rating scales and feedback on the performance of the group as a whole on each rated behavior. The evidence used to create the rating instruments was presented and participants had the opportunity to debate and agree on the instrument's construct validity. They then had the opportunity to engage in deliberate practice during role plays depicting challenges to orienting a learner, providing feedback, and to family centered rounds. The posttest OSTE served as summative evaluation of the participants' ability to perform the practiced behaviors effectively in a simulated teaching environment.

We chose to focus the FCR scenarios on correcting mistakes in clinical reasoning for a new patient and on teaching key parts of the physical exam during rounds for an established patient. Errors in clinical reasoning lead to misdirected patient management and are the number 1 cause of medical errors.19, 20 Bedside rounds are a perfect venue for reinforcing and fine‐tuning diagnostic reasoning because all the crucial sources of data are present: the patient, the parent, the nurse, and the computer with lab and imaging results. Faculty members and trainees have both expressed discomfort at correcting errors in clinical reasoning in front of families, leading to missed learning opportunities.21

During the workshop on clinical reasoning, we taught faculty how to use the Problem Representation method to analyze and correct errors in clinical reasoning. The method, studied by Bordage and associates22 forces learners to identify the key features of a presentation and relate their interpretation of the findings by using semantic qualifiers. We trained faculty to deliberately listen for the learner's interpretation of the key features to determine how a misdiagnosis occurred. They were also trained to walk trainees back through their thought process in an objective way, correcting the misinterpretation of data, so that the trainee's competence is not compromised in the eyes of the team or the parents. Teaching the trainee to think correctly about a clinical problem benefits the other members of the team, as well as providing the parents with a better understanding of the rationale for the management plan.

Correct interpretation of the physical exam findings is crucial to making the correct diagnosis. However, there have been several articles chronicling the lost art of eliciting and interpreting physical exam findings, ranging from the cardiac exam to neurological exam.23 A minority of physical exam teaching occurs at the patient's bedside, partly attributed to faculty members discomfort with this type of teaching.24, 25 To enhance the comfort of our faculty members, we included behaviors referenced in articles on teaching a skill,26 activated demonstration,10 and effective bedside teaching27 to guide faculty to incorporate eliciting and interpreting focused aspects of the physical exam during rounds.

Our FCR evaluation templates awarded the highest scores if the hospitalist encouraged senior residents to model clinical reasoning or physical exam skills for junior learners. Hospitalists' presence, especially on work rounds, can diminish the senior resident's opportunity to gain experience and confidence in leading the team.28 We therefore explicitly directed hospitalists to promote the role of the senior resident as the team leader during workshops, while priming faculty to assume the role of educational coach.29

We hypothesize that several factors contributed to the success of the OSTE workshopOSTE intervention. First, faculty members willingly volunteered to participate because they recognized gaps in their own knowledge and skill at leading FCR. They found the ability to deliberately practice the desired behaviors in the OSTE exercises to be the most useful part of the exercise, because the scenarios were authentic and SLs were real trainees.

Although we included all the junior faculty members of our large Pediatric Hospitalist Division in our study, our sample size is still small; limiting our ability to generalize our findings. We found the scheduling of 14 hospitalists to attend 4 different events in close succession to be problematic. Conducting the OSTE sessions at the GW CLASS center 5 miles away from our hospital was also logistically challenging.

We plan to simplify the logistics so that we can incorporate this model in the training of new hospitalists in the division. We still plan to use preintervention FCR OSTEs, but instead of workshops, will provide background information by means of self‐directed Web‐based modules. We will also videotape the OSTEs and provide faculty with a template to rate their own performance and then compare it with ratings from SLs. This individualized feedback and self‐reflection could result in better performance30 than the summary group feedback we gave during the workshops.

Another limitation of this study is the lack of data regarding the consistency of our faculty participants' performance in real FCR. Finally, we did not study the impact of the desired behaviors on patient, trainee, or nursing satisfaction, learning, or efficiency.

Conclusion

In conclusion, we found incorporating OSTEs into a faculty development program to improve FCR to be an effective strategy for changing faculty behavior in leading FCR. Additional study is needed to determine if replacing the workshops with Web‐based tutorials is equally effective and to determine if this faculty development strategy results in long‐term consistent practice in conducting rounds in real inpatient settings.

In Taiwan, the national health insurance (NHI) implemented since 19951 has extended its coverage to almost the entire population. It may serve as a model for other countries looking to implement a universal health insurance system.2, 3 However, due to the low copayment for services, there are increasing admission rates and hospitalizations.2, 4 Admission rates, in particular, have nearly tripled for those who have been previously uninsured prior to the NHI program.2 In terms of hospital care, internal medicine and surgery are not favorite areas of specialty in the NHI system because inpatient care has a high workload but relatively low salaries.2, 5, 6 Consequently, there is now a shortage of primary inpatient care staff in Taiwan. The hospitalist system may be a solution to this problem.

The role of a hospitalist system has been discussed since 1996.7 Although its pros and cons are still debatable,8 the hospitalist system has grown in recent decades and there is a wide acceptance that hospitalists can efficiently care for inpatients.4, 9, 10 However, most related studies are in Western countries.4, 6, 11 It has rarely been studied in Asian countries and in those with NHI programs.

This study therefore aimed to investigate whether the hospitalist system, working within the NHI system in Taiwan, can be efficient in saving costs, maintaining quality care, and managing a high volume of in patients.

Materials and Methods

This prospective observational study was conducted in the National Taiwan University Hospital (NTUH), a tertiary‐care referral center in northern Taiwan, and approved by the hospital's Institutional Review Board. The program was also registered on Clinicaltrial.gov (identifier NCT00997646). A 36‐bed hospitalist‐run ward (HW) was set up in October 2009 in NTUH. For performance comparison, two 36‐bed internist‐run wards (IWs) were selected. The three wards were geographically separated.

Results

From November 2009 to January 2010, 810 patients admitted from the ED to the study wards were enrolled. Among them, 377 were admitted to the HW and 433 to the IWs. Analysis of admission days showed that 84 (22%) and 53 (12%) patients were admitted to the HW and IWs, respectively, on weekends (P < 0.001).

Compared to the IW patients, the HW patients were older (age >65 years) and had poorer functional status by Barthel's scores (Table 2). Admission diagnosis was similar in both groups, except for pneumonia and urinary tract infection, which were higher in the HW patients. There was a primary care physician in 242 (64%) HW and 282 (65%) IW patients (P = 0.781).

The Charlson score, representing underlying comorbidity, was higher in the HW group (P = 0.002). Moreover, patients with severe liver cirrhosis (Child‐Pugh class C) were more frequently admitted to the HW (P = 0.018). Underlying malignancy, severe chronic kidney disease (estimated creatinine clearance <30 mL/min), and chronic respiratory failure requiring mechanical ventilator support were more associated with HW admission, although not statistically significantly (P = 0.064, 0.072, and 0.104, respectively).

The average admission cost was lower in HW patients than in IW patients, whether paid for by NHI ($1640.2 vs $2933.8 per patient, P = 0.001) or by the total admission cost ($2223.4 vs $3700.8 per patient, P = 0.001) (Table 3). Similarly, there was a shorter average length of stay (LOS) in the HW patients (9.3 vs 13.1 days, P < 0.001), who were discharged earlier than IW patients (Figure 1A). Regarding cost per patient‐day, the total daily cost was similar between the two groups (P = 0.560).

Figure 1

More patients in the HW group signed the do‐not‐resuscitate (DNR) consent (P < 0.001) and died during the hospital course, although the difference was not statistically significant (P = 0.068). Among those who expired during hospitalization, DNR consent was signed by 42 (90%) HW and 27 (68%) IW patients (P = 0.014). Among those discharged, 57 (17.2%) HW and 70 (17.6%) IW patients were lost to follow‐up. There was no difference in the 30‐day readmission for any cause between the two groups (P = 0.992).

Due to baseline differences, propensity score‐matching was performed and 101 pairs of patients were selected according to the probability generated from factors significantly different in univariate analysis (ie, age >65 years, pneumonia or urinary tract infections, Charlson score, Barthel's score, and blood urea nitrogen and C‐reactive protein levels on initial admission). The clinical characteristics of the 202 patients were shown in Table 4.

0

Both groups had almost the same propensity scores (P = 0.970; see online Supporting Information). Patients in the HW group had significantly lower admission cost, shorter LOS (Figure 1B), and more DNR consent, but similar in‐hospital mortality and readmission rates (Table 4).

DISCUSSION

The hospitalist system, which has been practiced for years in the United States, has not really been reported in Asia.13 Under the universal NHI system, this system has been studied in terms of treating patients in a Taiwan referral center. This study is the first to report on a hospitalist system in an Asian country with an NHI program. The hospitalist system in this study demonstrates efficient performance even though the patients have multiple comorbidities, compared to those in the general medical wards. By propensity score‐matching, admission costs of the hospitalist‐run ward are significantly lower than those of the internist‐run wards despite similar mortality and readmission rates.

The average LOS is reduced by 29% in HW patients and this plays a major role in cost reduction.14, 15 The reason may be the hospitalist's full‐time care, which allows for prompt decision‐making and close interaction with the patients' families.16 These families thus understand the treatment planning and prognosis. Furthermore, the hospitalist system continues working on weekends. As a result, patients are discharged without delay, even on holidays.

The aim of reducing LOS and costs is important because hospital income will decrease under the payment by disease‐related group (DRG) being implemented by the NHI system.17 A shortage of inpatient physicians may also develop due to the high workload but relatively low remuneration.2, 18 In contrast, a hospitalist care system that integrates nurse practitioners demands less human resources and saves on costs. In the future, it may be one of the solutions for hospitals aiming to maintain financial balance.

Another important issue in the NHI coverage is the increasing number of patients in the ED, which seems to be overflowing.19 In a previous Taiwan report, there are 7.1 patients per day who are staying in the ED for more than 72 hours, despite indications for admission.20 The delay is possibly due to the lack of available beds in the inpatient department.21 Amidst increasing demands for admission under the NHI and an aging society,2, 20 experience suggests that a hospitalist care system is a promising alternative to address the high ED patient volumes, especially on holidays. Howell et al. have also demonstrated that hospitalist‐driven bed management enhances the bed utility rate.21, 22 Since the current study also shows reduced LOS in the HW, patients will have a faster turn‐over rate and thereby assist in alleviating ED overcrowding.

Although the LOS of the patients here is comparable to that reported by the Taiwan NHI,2 it is far longer than that reported in the United States (around 4.75.2 days).4, 23 One possible explanation is the social and cultural determinants, including hospital‐ or physician‐dependence.24 In literature from Japan and Taiwan, hospitalization is as long as 13 weeks.25, 26 In addition, the average admission cost is reportedly around $1540 per patient‐day in the US, around 6 times that in this study ($266.6 per patient‐day).4 In the aging society of Taiwan,27 the NHI‐required copayment for admission may be relatively low, such that patients (or their families) may be misled that hospital care is better and hesitate to be discharged.2830

Regarding quality of care and patient safety, the in‐hospital mortality and the 30‐day readmission rates are similar in both groups, although disease severity and underlying comorbidities are worse in the HW at the start. This is consistent with previous reports that hospitalists can manage inpatient as well as internist care systems.4, 23 However, because this study has been performed in a tertiary referral center, patients may be more severely ill, such that the inpatient mortality and 30‐day readmission rates are as high as 10.3% and 21.11%, respectively.31, 32 Nonetheless, generalizing the hospitalist system to regional or district hospitals remains a concern, and this warrants further study.

This study has two other limitations. First, it is an observational study and patients have different demographics even though propensity score‐matching has been performed. Second, the patients were hospitalized without a standardized treatment protocol.

In conclusion, under the NHI system in Taiwan, a hospitalist system can have higher efficiency in shortening LOS and reducing cost than an internist care system, and still have similar hospital mortality and readmission rates. A hospitalist system may address the issue of high patient volume by increasing ward utilization. It can be recommended in a country with NHI that has a shortage of inpatient care staff.

In Taiwan, the national health insurance (NHI) implemented since 19951 has extended its coverage to almost the entire population. It may serve as a model for other countries looking to implement a universal health insurance system.2, 3 However, due to the low copayment for services, there are increasing admission rates and hospitalizations.2, 4 Admission rates, in particular, have nearly tripled for those who have been previously uninsured prior to the NHI program.2 In terms of hospital care, internal medicine and surgery are not favorite areas of specialty in the NHI system because inpatient care has a high workload but relatively low salaries.2, 5, 6 Consequently, there is now a shortage of primary inpatient care staff in Taiwan. The hospitalist system may be a solution to this problem.

The role of a hospitalist system has been discussed since 1996.7 Although its pros and cons are still debatable,8 the hospitalist system has grown in recent decades and there is a wide acceptance that hospitalists can efficiently care for inpatients.4, 9, 10 However, most related studies are in Western countries.4, 6, 11 It has rarely been studied in Asian countries and in those with NHI programs.

This study therefore aimed to investigate whether the hospitalist system, working within the NHI system in Taiwan, can be efficient in saving costs, maintaining quality care, and managing a high volume of in patients.

Materials and Methods

This prospective observational study was conducted in the National Taiwan University Hospital (NTUH), a tertiary‐care referral center in northern Taiwan, and approved by the hospital's Institutional Review Board. The program was also registered on Clinicaltrial.gov (identifier NCT00997646). A 36‐bed hospitalist‐run ward (HW) was set up in October 2009 in NTUH. For performance comparison, two 36‐bed internist‐run wards (IWs) were selected. The three wards were geographically separated.

Results

From November 2009 to January 2010, 810 patients admitted from the ED to the study wards were enrolled. Among them, 377 were admitted to the HW and 433 to the IWs. Analysis of admission days showed that 84 (22%) and 53 (12%) patients were admitted to the HW and IWs, respectively, on weekends (P < 0.001).

Compared to the IW patients, the HW patients were older (age >65 years) and had poorer functional status by Barthel's scores (Table 2). Admission diagnosis was similar in both groups, except for pneumonia and urinary tract infection, which were higher in the HW patients. There was a primary care physician in 242 (64%) HW and 282 (65%) IW patients (P = 0.781).

The Charlson score, representing underlying comorbidity, was higher in the HW group (P = 0.002). Moreover, patients with severe liver cirrhosis (Child‐Pugh class C) were more frequently admitted to the HW (P = 0.018). Underlying malignancy, severe chronic kidney disease (estimated creatinine clearance <30 mL/min), and chronic respiratory failure requiring mechanical ventilator support were more associated with HW admission, although not statistically significantly (P = 0.064, 0.072, and 0.104, respectively).

The average admission cost was lower in HW patients than in IW patients, whether paid for by NHI ($1640.2 vs $2933.8 per patient, P = 0.001) or by the total admission cost ($2223.4 vs $3700.8 per patient, P = 0.001) (Table 3). Similarly, there was a shorter average length of stay (LOS) in the HW patients (9.3 vs 13.1 days, P < 0.001), who were discharged earlier than IW patients (Figure 1A). Regarding cost per patient‐day, the total daily cost was similar between the two groups (P = 0.560).

Figure 1

More patients in the HW group signed the do‐not‐resuscitate (DNR) consent (P < 0.001) and died during the hospital course, although the difference was not statistically significant (P = 0.068). Among those who expired during hospitalization, DNR consent was signed by 42 (90%) HW and 27 (68%) IW patients (P = 0.014). Among those discharged, 57 (17.2%) HW and 70 (17.6%) IW patients were lost to follow‐up. There was no difference in the 30‐day readmission for any cause between the two groups (P = 0.992).

Due to baseline differences, propensity score‐matching was performed and 101 pairs of patients were selected according to the probability generated from factors significantly different in univariate analysis (ie, age >65 years, pneumonia or urinary tract infections, Charlson score, Barthel's score, and blood urea nitrogen and C‐reactive protein levels on initial admission). The clinical characteristics of the 202 patients were shown in Table 4.

0

Both groups had almost the same propensity scores (P = 0.970; see online Supporting Information). Patients in the HW group had significantly lower admission cost, shorter LOS (Figure 1B), and more DNR consent, but similar in‐hospital mortality and readmission rates (Table 4).

DISCUSSION

The hospitalist system, which has been practiced for years in the United States, has not really been reported in Asia.13 Under the universal NHI system, this system has been studied in terms of treating patients in a Taiwan referral center. This study is the first to report on a hospitalist system in an Asian country with an NHI program. The hospitalist system in this study demonstrates efficient performance even though the patients have multiple comorbidities, compared to those in the general medical wards. By propensity score‐matching, admission costs of the hospitalist‐run ward are significantly lower than those of the internist‐run wards despite similar mortality and readmission rates.

The average LOS is reduced by 29% in HW patients and this plays a major role in cost reduction.14, 15 The reason may be the hospitalist's full‐time care, which allows for prompt decision‐making and close interaction with the patients' families.16 These families thus understand the treatment planning and prognosis. Furthermore, the hospitalist system continues working on weekends. As a result, patients are discharged without delay, even on holidays.

The aim of reducing LOS and costs is important because hospital income will decrease under the payment by disease‐related group (DRG) being implemented by the NHI system.17 A shortage of inpatient physicians may also develop due to the high workload but relatively low remuneration.2, 18 In contrast, a hospitalist care system that integrates nurse practitioners demands less human resources and saves on costs. In the future, it may be one of the solutions for hospitals aiming to maintain financial balance.

Another important issue in the NHI coverage is the increasing number of patients in the ED, which seems to be overflowing.19 In a previous Taiwan report, there are 7.1 patients per day who are staying in the ED for more than 72 hours, despite indications for admission.20 The delay is possibly due to the lack of available beds in the inpatient department.21 Amidst increasing demands for admission under the NHI and an aging society,2, 20 experience suggests that a hospitalist care system is a promising alternative to address the high ED patient volumes, especially on holidays. Howell et al. have also demonstrated that hospitalist‐driven bed management enhances the bed utility rate.21, 22 Since the current study also shows reduced LOS in the HW, patients will have a faster turn‐over rate and thereby assist in alleviating ED overcrowding.

Although the LOS of the patients here is comparable to that reported by the Taiwan NHI,2 it is far longer than that reported in the United States (around 4.75.2 days).4, 23 One possible explanation is the social and cultural determinants, including hospital‐ or physician‐dependence.24 In literature from Japan and Taiwan, hospitalization is as long as 13 weeks.25, 26 In addition, the average admission cost is reportedly around $1540 per patient‐day in the US, around 6 times that in this study ($266.6 per patient‐day).4 In the aging society of Taiwan,27 the NHI‐required copayment for admission may be relatively low, such that patients (or their families) may be misled that hospital care is better and hesitate to be discharged.2830

Regarding quality of care and patient safety, the in‐hospital mortality and the 30‐day readmission rates are similar in both groups, although disease severity and underlying comorbidities are worse in the HW at the start. This is consistent with previous reports that hospitalists can manage inpatient as well as internist care systems.4, 23 However, because this study has been performed in a tertiary referral center, patients may be more severely ill, such that the inpatient mortality and 30‐day readmission rates are as high as 10.3% and 21.11%, respectively.31, 32 Nonetheless, generalizing the hospitalist system to regional or district hospitals remains a concern, and this warrants further study.

This study has two other limitations. First, it is an observational study and patients have different demographics even though propensity score‐matching has been performed. Second, the patients were hospitalized without a standardized treatment protocol.

In conclusion, under the NHI system in Taiwan, a hospitalist system can have higher efficiency in shortening LOS and reducing cost than an internist care system, and still have similar hospital mortality and readmission rates. A hospitalist system may address the issue of high patient volume by increasing ward utilization. It can be recommended in a country with NHI that has a shortage of inpatient care staff.

In Taiwan, the national health insurance (NHI) implemented since 19951 has extended its coverage to almost the entire population. It may serve as a model for other countries looking to implement a universal health insurance system.2, 3 However, due to the low copayment for services, there are increasing admission rates and hospitalizations.2, 4 Admission rates, in particular, have nearly tripled for those who have been previously uninsured prior to the NHI program.2 In terms of hospital care, internal medicine and surgery are not favorite areas of specialty in the NHI system because inpatient care has a high workload but relatively low salaries.2, 5, 6 Consequently, there is now a shortage of primary inpatient care staff in Taiwan. The hospitalist system may be a solution to this problem.

The role of a hospitalist system has been discussed since 1996.7 Although its pros and cons are still debatable,8 the hospitalist system has grown in recent decades and there is a wide acceptance that hospitalists can efficiently care for inpatients.4, 9, 10 However, most related studies are in Western countries.4, 6, 11 It has rarely been studied in Asian countries and in those with NHI programs.

This study therefore aimed to investigate whether the hospitalist system, working within the NHI system in Taiwan, can be efficient in saving costs, maintaining quality care, and managing a high volume of in patients.

Materials and Methods

This prospective observational study was conducted in the National Taiwan University Hospital (NTUH), a tertiary‐care referral center in northern Taiwan, and approved by the hospital's Institutional Review Board. The program was also registered on Clinicaltrial.gov (identifier NCT00997646). A 36‐bed hospitalist‐run ward (HW) was set up in October 2009 in NTUH. For performance comparison, two 36‐bed internist‐run wards (IWs) were selected. The three wards were geographically separated.

Results

From November 2009 to January 2010, 810 patients admitted from the ED to the study wards were enrolled. Among them, 377 were admitted to the HW and 433 to the IWs. Analysis of admission days showed that 84 (22%) and 53 (12%) patients were admitted to the HW and IWs, respectively, on weekends (P < 0.001).

Compared to the IW patients, the HW patients were older (age >65 years) and had poorer functional status by Barthel's scores (Table 2). Admission diagnosis was similar in both groups, except for pneumonia and urinary tract infection, which were higher in the HW patients. There was a primary care physician in 242 (64%) HW and 282 (65%) IW patients (P = 0.781).

The Charlson score, representing underlying comorbidity, was higher in the HW group (P = 0.002). Moreover, patients with severe liver cirrhosis (Child‐Pugh class C) were more frequently admitted to the HW (P = 0.018). Underlying malignancy, severe chronic kidney disease (estimated creatinine clearance <30 mL/min), and chronic respiratory failure requiring mechanical ventilator support were more associated with HW admission, although not statistically significantly (P = 0.064, 0.072, and 0.104, respectively).

The average admission cost was lower in HW patients than in IW patients, whether paid for by NHI ($1640.2 vs $2933.8 per patient, P = 0.001) or by the total admission cost ($2223.4 vs $3700.8 per patient, P = 0.001) (Table 3). Similarly, there was a shorter average length of stay (LOS) in the HW patients (9.3 vs 13.1 days, P < 0.001), who were discharged earlier than IW patients (Figure 1A). Regarding cost per patient‐day, the total daily cost was similar between the two groups (P = 0.560).

Figure 1

More patients in the HW group signed the do‐not‐resuscitate (DNR) consent (P < 0.001) and died during the hospital course, although the difference was not statistically significant (P = 0.068). Among those who expired during hospitalization, DNR consent was signed by 42 (90%) HW and 27 (68%) IW patients (P = 0.014). Among those discharged, 57 (17.2%) HW and 70 (17.6%) IW patients were lost to follow‐up. There was no difference in the 30‐day readmission for any cause between the two groups (P = 0.992).

Due to baseline differences, propensity score‐matching was performed and 101 pairs of patients were selected according to the probability generated from factors significantly different in univariate analysis (ie, age >65 years, pneumonia or urinary tract infections, Charlson score, Barthel's score, and blood urea nitrogen and C‐reactive protein levels on initial admission). The clinical characteristics of the 202 patients were shown in Table 4.

0

Both groups had almost the same propensity scores (P = 0.970; see online Supporting Information). Patients in the HW group had significantly lower admission cost, shorter LOS (Figure 1B), and more DNR consent, but similar in‐hospital mortality and readmission rates (Table 4).

DISCUSSION

The hospitalist system, which has been practiced for years in the United States, has not really been reported in Asia.13 Under the universal NHI system, this system has been studied in terms of treating patients in a Taiwan referral center. This study is the first to report on a hospitalist system in an Asian country with an NHI program. The hospitalist system in this study demonstrates efficient performance even though the patients have multiple comorbidities, compared to those in the general medical wards. By propensity score‐matching, admission costs of the hospitalist‐run ward are significantly lower than those of the internist‐run wards despite similar mortality and readmission rates.

The average LOS is reduced by 29% in HW patients and this plays a major role in cost reduction.14, 15 The reason may be the hospitalist's full‐time care, which allows for prompt decision‐making and close interaction with the patients' families.16 These families thus understand the treatment planning and prognosis. Furthermore, the hospitalist system continues working on weekends. As a result, patients are discharged without delay, even on holidays.

The aim of reducing LOS and costs is important because hospital income will decrease under the payment by disease‐related group (DRG) being implemented by the NHI system.17 A shortage of inpatient physicians may also develop due to the high workload but relatively low remuneration.2, 18 In contrast, a hospitalist care system that integrates nurse practitioners demands less human resources and saves on costs. In the future, it may be one of the solutions for hospitals aiming to maintain financial balance.

Another important issue in the NHI coverage is the increasing number of patients in the ED, which seems to be overflowing.19 In a previous Taiwan report, there are 7.1 patients per day who are staying in the ED for more than 72 hours, despite indications for admission.20 The delay is possibly due to the lack of available beds in the inpatient department.21 Amidst increasing demands for admission under the NHI and an aging society,2, 20 experience suggests that a hospitalist care system is a promising alternative to address the high ED patient volumes, especially on holidays. Howell et al. have also demonstrated that hospitalist‐driven bed management enhances the bed utility rate.21, 22 Since the current study also shows reduced LOS in the HW, patients will have a faster turn‐over rate and thereby assist in alleviating ED overcrowding.

Although the LOS of the patients here is comparable to that reported by the Taiwan NHI,2 it is far longer than that reported in the United States (around 4.75.2 days).4, 23 One possible explanation is the social and cultural determinants, including hospital‐ or physician‐dependence.24 In literature from Japan and Taiwan, hospitalization is as long as 13 weeks.25, 26 In addition, the average admission cost is reportedly around $1540 per patient‐day in the US, around 6 times that in this study ($266.6 per patient‐day).4 In the aging society of Taiwan,27 the NHI‐required copayment for admission may be relatively low, such that patients (or their families) may be misled that hospital care is better and hesitate to be discharged.2830

Regarding quality of care and patient safety, the in‐hospital mortality and the 30‐day readmission rates are similar in both groups, although disease severity and underlying comorbidities are worse in the HW at the start. This is consistent with previous reports that hospitalists can manage inpatient as well as internist care systems.4, 23 However, because this study has been performed in a tertiary referral center, patients may be more severely ill, such that the inpatient mortality and 30‐day readmission rates are as high as 10.3% and 21.11%, respectively.31, 32 Nonetheless, generalizing the hospitalist system to regional or district hospitals remains a concern, and this warrants further study.

This study has two other limitations. First, it is an observational study and patients have different demographics even though propensity score‐matching has been performed. Second, the patients were hospitalized without a standardized treatment protocol.

In conclusion, under the NHI system in Taiwan, a hospitalist system can have higher efficiency in shortening LOS and reducing cost than an internist care system, and still have similar hospital mortality and readmission rates. A hospitalist system may address the issue of high patient volume by increasing ward utilization. It can be recommended in a country with NHI that has a shortage of inpatient care staff.

Comanagement is common in hospital medicine practice. And yet, there is no consensus about how comanagement is different from traditional consultative practice. At its core, hospitalist comanagement is a practice arrangement wherein hospitalists and other specialists manage complex patients collaboratively. Beyond this, Huddleston et al. distinguish comanagement from traditional consultations in the comanaging hospitalists' prerogative to provide direct medical care in addition to consultative advice.1 Siegal focuses on the shared responsibility and authority among partnering providers in the comanagement model.2 Whinney and Michota see comanagement as patient care referral at the onset of a care episode, in contrast to consultations that are activated to address emergent problems.3 In a recent study that found the growing adoption of medical comanagement in Medicare beneficiaries (as much as 40% of surgical hospitalizations in 2006), comanagement was defined as an intensive form of consultation involving a claim for evaluation and management services on greater than 70% of inpatient days.4

In addition to the intensity, frequency, timing, responsibility, and authority of care, comanagement may be described by participating physicians' roles. With recent attention on multidisciplinary teams and an increasing focus on collaborative care, many of the hierarchical relations among healthcare providers are breaking down.5 Several studies of multidisciplinary teams suggest that more egalitarian, rather than hierarchical, problem‐solving and decision‐making among team members are beneficial to patients.67 However, neither the intended nor natural team structure under comanagement is known. We sought to shed some light on provider interactions by characterizing the expectations and experiences of providers of a comanaged service. The findings yielded an opportunity to generate an evolving, but conceptually supported definition of comanagement.

SETTING

We conducted a survey study of providers participating in a comanaged inpatient hepatology service at the University of Chicago Medical Center, a 572‐bed urban teaching hospital. The service was created in 2006, partly to address staffing problems related to housestaff work hour restrictions and partly to improve the care of candidates and recipients of liver transplantation. Nonsurgical floor patients with liver diseases were managed on the service by two collaborating teams of providers. The hepatology team consisted of an attending physician and a fellow, while the hospitalist team consisted of a hospitalist and one or two nonphysician providers (physician assistant or nurse practitioner). The practice model is characterized as comanagement because of the highly interdependent nature of the team's daily tasks and the norms of intensive communication, through formal joint daily rounds and informal direct exchanges of instructions and updates. Hepatologists were mainly responsible for coordinating admissions, managing issues related to liver dysfunction, communicating with transplant surgeons if necessary, and arranging postdischarge care. Hospitalists were responsible for admitting patients, managing routine (eg, ordering daily labs) and urgent issues (eg, responding to critical lab values) during hospitalizations, coordinating with ancillary and consultative staff, and discharging patients. Occasional meetings between the hepatology and hospital medicine groups were used to clarify assignment of responsibilities. Floor nurses received in‐servicing at the commencement of the service. Additional details about the service are described elsewhere.8

DATA COLLECTION AND ANALYSIS

For the purpose of our analysis, we defined interactions between any member of the hospitalist and hepatologist teams as pertinent to comanagement. The hospitalist nonphysician provider (NPP) and hepatologistfellow relationships are governed by the more traditional hierarchical dynamics based on supervision and authority according to laws and regulations. At the beginning of the study period, each participant completed nine items of a Baseline Survey that addressed respondents' expectations and preferences for the management of an ideally comanaged service. Responses were solicited using a 4‐point Likert‐type scale and were dichotomized such that agree and somewhat agree were grouped, while disagree and somewhat disagree were grouped for data analysis. Items were generated to address the salient issues of comanagement after reviewing the pertinent literature.

Subsequently, participants were asked to complete Repeated Surveys immediately before each change in membership of the comanaged team between April and October 2008. The surveys were hand delivered by one of the authors (K.H.) on the last day of each team's rotation and were often completed immediately. The seven items of the Repeated Survey reprised items from the Baseline Survey that were rephrased to allow respondents to report their direct experiences on specific teams. Because all providers rotated on the service more than once during the study period, the average value for each Likert‐type response across multiple surveys completed by a single provider was calculated before being dichotomized at the midpoint (<2.5, agree; 2.5, disagree). We reported proportions of respondents in agreement with survey item statements.

Comparison statistics across providers were generated using the chi‐square test. Differences in proportions between related items of the Baseline and Repeated Surveys were compared using the two‐sample test of proportions. All analyses were conducted using a statistics application (STATA 10.0, College Station, TX) with alpha equal to, or less than, 0.05 considered significant. The Institutional Review Board of the University of Chicago approved this project.

RESULTS

All 43 providers completed the Baseline Survey. During the study period, 32 of these participants rotated on the service and completed 177 of the 233 Repeated Surveys (79%) administered. The responses describe team interactions on the 47 unique combinations of providers comprising the comanaged teams. Details of the response rates are shown in Table 1.

As shown in Table 2A, items 13, more members of the hospitalist team preferred to be informed about every management decision compared to members of the hepatologist team. Conversely, more of members of the hepatologist team than the hospitalist team preferred their comanaging partners to participate in every decision. A statistically similar proportion of respondents in each of the professional roles indicated desire for greater influence in directing management decisions (Table 2B, item 1).

For the majority of surveyed areas, there was concordance between expectations and experiences of providers on comanagement. Most providers, regardless of professional role, agreed that there should be a single physician leader to direct the overall management (Table 2A, item 5). The majority perceived that a single physician directed the overall management of the patients' hospital course, although fewer hospitalists did so compared with baseline expectations (Table 2B, item 3). Many respondents felt at baseline that physician consensus should govern every management decision, and a similar proportion actually experienced consensus‐seeking on service.

We found that the proportion of providers reporting an understanding of their role increased slightly, though not significantly, from before (Table 2A, item 7) to after rotating on the comanaged service (Table 2B, item 5). Although not statistically significant, there was a trend towards hospitalists and gastrointestinal (GI) fellows reporting a lack of patient ownership, both before and after serving on the comanaged service. Finally, nearly all respondents reported that comanagement should improve care quality, although only the attending hospitalist and hepatologist felt that their experience on the comanaged service actually improved patient care (Table 2B, item 7).

DISCUSSION

In this survey of providers participating on a comanaged medical service, most reported understanding their role in the collaborative arrangement and had an initial perception that comanagement should improve patient care quality. We found that hospitalists preferred and were expected to participate in care globally, while hepatologists themselves preferred and were expected not to focus on every management decision. The prevalence of desire for ultimate authority across the professional roles suggests tensions that exist in this care model around how decisions are made. The majority of providers preferred and experienced a single physician leader under comanagement, but many also experienced consensus‐seeking for every management decision.

From these findings, we conclude that decision‐making processes are not uniform under comanagement and that some role ambiguity is present, but there appears to be a pattern of natural roles. This pattern can be defined by focus (general for hospitalists vs specialty‐specific for hepatologists), rather than by responsibilities for managing particular medical problems. The preference among both generalists and specialists for the broader involvement of hospitalist comanagers suggests an implicit recognition of the need for integrated management to overcome the silo‐effect within the comanagement structure.9 Although details about how such integration was achieved are not available in our data, we found that comanagement may be distinct from traditional consultative practice in that the consultants (hospitalists in this case) manage not only general medical problems, such as diabetes or hypertension, but hospitalizations more generally. From a mission‐based standpoint, comanagement may be seen as a collaborative management of complex patients by two or more clinical experts with distinct knowledge, skills, or focus enacted for the purpose of improving care quality.

The focus of comanagement on improving quality is in line with the founding charge of the hospital medicine specialty to raise hospital care quality.10 In fact, the distinction between comanagement and consultation may be meaningful only if comanagers can work with specialists to implement evidence‐based practice, process improvement, and address quality and cost concerns. But as seen in NPPs and fellows' skepticism of improved quality under comanagement, there is still clearly work to be done to validate this model through measurable improvement in patients' experiences and outcomes. Proving the advantages of comanagement as a platform for practice improvement remains future work.11

Collaborative arrangements create natural tensions related to team function.5 This is seen in the similar proportion of hospitalists and hepatologists indicating desire for final decision‐making authority. Although comanagement evokes assumptions about egalitarian provider interactions involving shared decision‐making and responsibility, it seems to function empirically under hierarchical as well as consensus‐seeking forms of decision‐making. Providers at the top of hierarchical teams typically experience their work as interdependent and collaborative, and report more positive interactions with other care providers.12 Based on the fact that no hepatologists wanted more influence over decision‐making, we assume that hepatologists were the physician leaders for most of the studied comanaged teams. Under situations characterized by high levels of complexity and interdependence, a team governed by a single leader may often be more effective than one governed by shared authority.8 However, even under hierarchical models, a more participatory than supervisory leadership can help avoid alienating partners through a pattern of we decide, you carry it out that is often associated with ineffective leadership styles.1314 In fact, this alienating effect on providers in subordinate roles (ie, NPPs and fellows) may have contributed to the negative perception of the team's function on improving patient care.

This study is limited in the following ways. We did not have 100% participation in the Repeated Surveys. Attitudes and experiences of participants in a single comanagement practice are not representative of all comanaging providers. However, the goal of this studyto collect unique survey data from providers themselves to inform an evolving definition of comanagementis modest enough in scope to not require a generalizable sample. Because this study unearthed differences in expectations and experiences within a single site, they may serve as a lower bound for the extent of differences across and within multiple sites. In addition, comanagement enacted for complex medical patients is not as common as the comanagement of surgical patients. Moreover, comanagement models in academic hospitals may have structural features and priorities not found in community settings. Whether or not these disparate models share enough in common to be categorized under a single rubric is a valid question.

Although the teamwork structure and provider roles within comanagement vary, the practice arrangement's preoccupation with quality can be seen as its defining feature. Limited evidence, to date,1, 1519 and the rapid proliferation of the model, suggest that quality and efficiency advantages can be obtained from an effective implementation of comanagement. As in any team‐based care model, a common understanding of roles and expectations are essential to enhancing teamwork. Our interpretation of the mission of comanagement may further enhance teamwork through an explicit articulation of shared goals.

Comanagement is common in hospital medicine practice. And yet, there is no consensus about how comanagement is different from traditional consultative practice. At its core, hospitalist comanagement is a practice arrangement wherein hospitalists and other specialists manage complex patients collaboratively. Beyond this, Huddleston et al. distinguish comanagement from traditional consultations in the comanaging hospitalists' prerogative to provide direct medical care in addition to consultative advice.1 Siegal focuses on the shared responsibility and authority among partnering providers in the comanagement model.2 Whinney and Michota see comanagement as patient care referral at the onset of a care episode, in contrast to consultations that are activated to address emergent problems.3 In a recent study that found the growing adoption of medical comanagement in Medicare beneficiaries (as much as 40% of surgical hospitalizations in 2006), comanagement was defined as an intensive form of consultation involving a claim for evaluation and management services on greater than 70% of inpatient days.4

In addition to the intensity, frequency, timing, responsibility, and authority of care, comanagement may be described by participating physicians' roles. With recent attention on multidisciplinary teams and an increasing focus on collaborative care, many of the hierarchical relations among healthcare providers are breaking down.5 Several studies of multidisciplinary teams suggest that more egalitarian, rather than hierarchical, problem‐solving and decision‐making among team members are beneficial to patients.67 However, neither the intended nor natural team structure under comanagement is known. We sought to shed some light on provider interactions by characterizing the expectations and experiences of providers of a comanaged service. The findings yielded an opportunity to generate an evolving, but conceptually supported definition of comanagement.

SETTING

We conducted a survey study of providers participating in a comanaged inpatient hepatology service at the University of Chicago Medical Center, a 572‐bed urban teaching hospital. The service was created in 2006, partly to address staffing problems related to housestaff work hour restrictions and partly to improve the care of candidates and recipients of liver transplantation. Nonsurgical floor patients with liver diseases were managed on the service by two collaborating teams of providers. The hepatology team consisted of an attending physician and a fellow, while the hospitalist team consisted of a hospitalist and one or two nonphysician providers (physician assistant or nurse practitioner). The practice model is characterized as comanagement because of the highly interdependent nature of the team's daily tasks and the norms of intensive communication, through formal joint daily rounds and informal direct exchanges of instructions and updates. Hepatologists were mainly responsible for coordinating admissions, managing issues related to liver dysfunction, communicating with transplant surgeons if necessary, and arranging postdischarge care. Hospitalists were responsible for admitting patients, managing routine (eg, ordering daily labs) and urgent issues (eg, responding to critical lab values) during hospitalizations, coordinating with ancillary and consultative staff, and discharging patients. Occasional meetings between the hepatology and hospital medicine groups were used to clarify assignment of responsibilities. Floor nurses received in‐servicing at the commencement of the service. Additional details about the service are described elsewhere.8

DATA COLLECTION AND ANALYSIS

For the purpose of our analysis, we defined interactions between any member of the hospitalist and hepatologist teams as pertinent to comanagement. The hospitalist nonphysician provider (NPP) and hepatologistfellow relationships are governed by the more traditional hierarchical dynamics based on supervision and authority according to laws and regulations. At the beginning of the study period, each participant completed nine items of a Baseline Survey that addressed respondents' expectations and preferences for the management of an ideally comanaged service. Responses were solicited using a 4‐point Likert‐type scale and were dichotomized such that agree and somewhat agree were grouped, while disagree and somewhat disagree were grouped for data analysis. Items were generated to address the salient issues of comanagement after reviewing the pertinent literature.

Subsequently, participants were asked to complete Repeated Surveys immediately before each change in membership of the comanaged team between April and October 2008. The surveys were hand delivered by one of the authors (K.H.) on the last day of each team's rotation and were often completed immediately. The seven items of the Repeated Survey reprised items from the Baseline Survey that were rephrased to allow respondents to report their direct experiences on specific teams. Because all providers rotated on the service more than once during the study period, the average value for each Likert‐type response across multiple surveys completed by a single provider was calculated before being dichotomized at the midpoint (<2.5, agree; 2.5, disagree). We reported proportions of respondents in agreement with survey item statements.

Comparison statistics across providers were generated using the chi‐square test. Differences in proportions between related items of the Baseline and Repeated Surveys were compared using the two‐sample test of proportions. All analyses were conducted using a statistics application (STATA 10.0, College Station, TX) with alpha equal to, or less than, 0.05 considered significant. The Institutional Review Board of the University of Chicago approved this project.

RESULTS

All 43 providers completed the Baseline Survey. During the study period, 32 of these participants rotated on the service and completed 177 of the 233 Repeated Surveys (79%) administered. The responses describe team interactions on the 47 unique combinations of providers comprising the comanaged teams. Details of the response rates are shown in Table 1.

As shown in Table 2A, items 13, more members of the hospitalist team preferred to be informed about every management decision compared to members of the hepatologist team. Conversely, more of members of the hepatologist team than the hospitalist team preferred their comanaging partners to participate in every decision. A statistically similar proportion of respondents in each of the professional roles indicated desire for greater influence in directing management decisions (Table 2B, item 1).

For the majority of surveyed areas, there was concordance between expectations and experiences of providers on comanagement. Most providers, regardless of professional role, agreed that there should be a single physician leader to direct the overall management (Table 2A, item 5). The majority perceived that a single physician directed the overall management of the patients' hospital course, although fewer hospitalists did so compared with baseline expectations (Table 2B, item 3). Many respondents felt at baseline that physician consensus should govern every management decision, and a similar proportion actually experienced consensus‐seeking on service.

We found that the proportion of providers reporting an understanding of their role increased slightly, though not significantly, from before (Table 2A, item 7) to after rotating on the comanaged service (Table 2B, item 5). Although not statistically significant, there was a trend towards hospitalists and gastrointestinal (GI) fellows reporting a lack of patient ownership, both before and after serving on the comanaged service. Finally, nearly all respondents reported that comanagement should improve care quality, although only the attending hospitalist and hepatologist felt that their experience on the comanaged service actually improved patient care (Table 2B, item 7).

DISCUSSION

In this survey of providers participating on a comanaged medical service, most reported understanding their role in the collaborative arrangement and had an initial perception that comanagement should improve patient care quality. We found that hospitalists preferred and were expected to participate in care globally, while hepatologists themselves preferred and were expected not to focus on every management decision. The prevalence of desire for ultimate authority across the professional roles suggests tensions that exist in this care model around how decisions are made. The majority of providers preferred and experienced a single physician leader under comanagement, but many also experienced consensus‐seeking for every management decision.

From these findings, we conclude that decision‐making processes are not uniform under comanagement and that some role ambiguity is present, but there appears to be a pattern of natural roles. This pattern can be defined by focus (general for hospitalists vs specialty‐specific for hepatologists), rather than by responsibilities for managing particular medical problems. The preference among both generalists and specialists for the broader involvement of hospitalist comanagers suggests an implicit recognition of the need for integrated management to overcome the silo‐effect within the comanagement structure.9 Although details about how such integration was achieved are not available in our data, we found that comanagement may be distinct from traditional consultative practice in that the consultants (hospitalists in this case) manage not only general medical problems, such as diabetes or hypertension, but hospitalizations more generally. From a mission‐based standpoint, comanagement may be seen as a collaborative management of complex patients by two or more clinical experts with distinct knowledge, skills, or focus enacted for the purpose of improving care quality.

The focus of comanagement on improving quality is in line with the founding charge of the hospital medicine specialty to raise hospital care quality.10 In fact, the distinction between comanagement and consultation may be meaningful only if comanagers can work with specialists to implement evidence‐based practice, process improvement, and address quality and cost concerns. But as seen in NPPs and fellows' skepticism of improved quality under comanagement, there is still clearly work to be done to validate this model through measurable improvement in patients' experiences and outcomes. Proving the advantages of comanagement as a platform for practice improvement remains future work.11

Collaborative arrangements create natural tensions related to team function.5 This is seen in the similar proportion of hospitalists and hepatologists indicating desire for final decision‐making authority. Although comanagement evokes assumptions about egalitarian provider interactions involving shared decision‐making and responsibility, it seems to function empirically under hierarchical as well as consensus‐seeking forms of decision‐making. Providers at the top of hierarchical teams typically experience their work as interdependent and collaborative, and report more positive interactions with other care providers.12 Based on the fact that no hepatologists wanted more influence over decision‐making, we assume that hepatologists were the physician leaders for most of the studied comanaged teams. Under situations characterized by high levels of complexity and interdependence, a team governed by a single leader may often be more effective than one governed by shared authority.8 However, even under hierarchical models, a more participatory than supervisory leadership can help avoid alienating partners through a pattern of we decide, you carry it out that is often associated with ineffective leadership styles.1314 In fact, this alienating effect on providers in subordinate roles (ie, NPPs and fellows) may have contributed to the negative perception of the team's function on improving patient care.

This study is limited in the following ways. We did not have 100% participation in the Repeated Surveys. Attitudes and experiences of participants in a single comanagement practice are not representative of all comanaging providers. However, the goal of this studyto collect unique survey data from providers themselves to inform an evolving definition of comanagementis modest enough in scope to not require a generalizable sample. Because this study unearthed differences in expectations and experiences within a single site, they may serve as a lower bound for the extent of differences across and within multiple sites. In addition, comanagement enacted for complex medical patients is not as common as the comanagement of surgical patients. Moreover, comanagement models in academic hospitals may have structural features and priorities not found in community settings. Whether or not these disparate models share enough in common to be categorized under a single rubric is a valid question.

Although the teamwork structure and provider roles within comanagement vary, the practice arrangement's preoccupation with quality can be seen as its defining feature. Limited evidence, to date,1, 1519 and the rapid proliferation of the model, suggest that quality and efficiency advantages can be obtained from an effective implementation of comanagement. As in any team‐based care model, a common understanding of roles and expectations are essential to enhancing teamwork. Our interpretation of the mission of comanagement may further enhance teamwork through an explicit articulation of shared goals.

Comanagement is common in hospital medicine practice. And yet, there is no consensus about how comanagement is different from traditional consultative practice. At its core, hospitalist comanagement is a practice arrangement wherein hospitalists and other specialists manage complex patients collaboratively. Beyond this, Huddleston et al. distinguish comanagement from traditional consultations in the comanaging hospitalists' prerogative to provide direct medical care in addition to consultative advice.1 Siegal focuses on the shared responsibility and authority among partnering providers in the comanagement model.2 Whinney and Michota see comanagement as patient care referral at the onset of a care episode, in contrast to consultations that are activated to address emergent problems.3 In a recent study that found the growing adoption of medical comanagement in Medicare beneficiaries (as much as 40% of surgical hospitalizations in 2006), comanagement was defined as an intensive form of consultation involving a claim for evaluation and management services on greater than 70% of inpatient days.4

In addition to the intensity, frequency, timing, responsibility, and authority of care, comanagement may be described by participating physicians' roles. With recent attention on multidisciplinary teams and an increasing focus on collaborative care, many of the hierarchical relations among healthcare providers are breaking down.5 Several studies of multidisciplinary teams suggest that more egalitarian, rather than hierarchical, problem‐solving and decision‐making among team members are beneficial to patients.67 However, neither the intended nor natural team structure under comanagement is known. We sought to shed some light on provider interactions by characterizing the expectations and experiences of providers of a comanaged service. The findings yielded an opportunity to generate an evolving, but conceptually supported definition of comanagement.

SETTING

We conducted a survey study of providers participating in a comanaged inpatient hepatology service at the University of Chicago Medical Center, a 572‐bed urban teaching hospital. The service was created in 2006, partly to address staffing problems related to housestaff work hour restrictions and partly to improve the care of candidates and recipients of liver transplantation. Nonsurgical floor patients with liver diseases were managed on the service by two collaborating teams of providers. The hepatology team consisted of an attending physician and a fellow, while the hospitalist team consisted of a hospitalist and one or two nonphysician providers (physician assistant or nurse practitioner). The practice model is characterized as comanagement because of the highly interdependent nature of the team's daily tasks and the norms of intensive communication, through formal joint daily rounds and informal direct exchanges of instructions and updates. Hepatologists were mainly responsible for coordinating admissions, managing issues related to liver dysfunction, communicating with transplant surgeons if necessary, and arranging postdischarge care. Hospitalists were responsible for admitting patients, managing routine (eg, ordering daily labs) and urgent issues (eg, responding to critical lab values) during hospitalizations, coordinating with ancillary and consultative staff, and discharging patients. Occasional meetings between the hepatology and hospital medicine groups were used to clarify assignment of responsibilities. Floor nurses received in‐servicing at the commencement of the service. Additional details about the service are described elsewhere.8

DATA COLLECTION AND ANALYSIS

For the purpose of our analysis, we defined interactions between any member of the hospitalist and hepatologist teams as pertinent to comanagement. The hospitalist nonphysician provider (NPP) and hepatologistfellow relationships are governed by the more traditional hierarchical dynamics based on supervision and authority according to laws and regulations. At the beginning of the study period, each participant completed nine items of a Baseline Survey that addressed respondents' expectations and preferences for the management of an ideally comanaged service. Responses were solicited using a 4‐point Likert‐type scale and were dichotomized such that agree and somewhat agree were grouped, while disagree and somewhat disagree were grouped for data analysis. Items were generated to address the salient issues of comanagement after reviewing the pertinent literature.

Subsequently, participants were asked to complete Repeated Surveys immediately before each change in membership of the comanaged team between April and October 2008. The surveys were hand delivered by one of the authors (K.H.) on the last day of each team's rotation and were often completed immediately. The seven items of the Repeated Survey reprised items from the Baseline Survey that were rephrased to allow respondents to report their direct experiences on specific teams. Because all providers rotated on the service more than once during the study period, the average value for each Likert‐type response across multiple surveys completed by a single provider was calculated before being dichotomized at the midpoint (<2.5, agree; 2.5, disagree). We reported proportions of respondents in agreement with survey item statements.

Comparison statistics across providers were generated using the chi‐square test. Differences in proportions between related items of the Baseline and Repeated Surveys were compared using the two‐sample test of proportions. All analyses were conducted using a statistics application (STATA 10.0, College Station, TX) with alpha equal to, or less than, 0.05 considered significant. The Institutional Review Board of the University of Chicago approved this project.

RESULTS

All 43 providers completed the Baseline Survey. During the study period, 32 of these participants rotated on the service and completed 177 of the 233 Repeated Surveys (79%) administered. The responses describe team interactions on the 47 unique combinations of providers comprising the comanaged teams. Details of the response rates are shown in Table 1.

As shown in Table 2A, items 13, more members of the hospitalist team preferred to be informed about every management decision compared to members of the hepatologist team. Conversely, more of members of the hepatologist team than the hospitalist team preferred their comanaging partners to participate in every decision. A statistically similar proportion of respondents in each of the professional roles indicated desire for greater influence in directing management decisions (Table 2B, item 1).

For the majority of surveyed areas, there was concordance between expectations and experiences of providers on comanagement. Most providers, regardless of professional role, agreed that there should be a single physician leader to direct the overall management (Table 2A, item 5). The majority perceived that a single physician directed the overall management of the patients' hospital course, although fewer hospitalists did so compared with baseline expectations (Table 2B, item 3). Many respondents felt at baseline that physician consensus should govern every management decision, and a similar proportion actually experienced consensus‐seeking on service.

We found that the proportion of providers reporting an understanding of their role increased slightly, though not significantly, from before (Table 2A, item 7) to after rotating on the comanaged service (Table 2B, item 5). Although not statistically significant, there was a trend towards hospitalists and gastrointestinal (GI) fellows reporting a lack of patient ownership, both before and after serving on the comanaged service. Finally, nearly all respondents reported that comanagement should improve care quality, although only the attending hospitalist and hepatologist felt that their experience on the comanaged service actually improved patient care (Table 2B, item 7).

DISCUSSION

In this survey of providers participating on a comanaged medical service, most reported understanding their role in the collaborative arrangement and had an initial perception that comanagement should improve patient care quality. We found that hospitalists preferred and were expected to participate in care globally, while hepatologists themselves preferred and were expected not to focus on every management decision. The prevalence of desire for ultimate authority across the professional roles suggests tensions that exist in this care model around how decisions are made. The majority of providers preferred and experienced a single physician leader under comanagement, but many also experienced consensus‐seeking for every management decision.

From these findings, we conclude that decision‐making processes are not uniform under comanagement and that some role ambiguity is present, but there appears to be a pattern of natural roles. This pattern can be defined by focus (general for hospitalists vs specialty‐specific for hepatologists), rather than by responsibilities for managing particular medical problems. The preference among both generalists and specialists for the broader involvement of hospitalist comanagers suggests an implicit recognition of the need for integrated management to overcome the silo‐effect within the comanagement structure.9 Although details about how such integration was achieved are not available in our data, we found that comanagement may be distinct from traditional consultative practice in that the consultants (hospitalists in this case) manage not only general medical problems, such as diabetes or hypertension, but hospitalizations more generally. From a mission‐based standpoint, comanagement may be seen as a collaborative management of complex patients by two or more clinical experts with distinct knowledge, skills, or focus enacted for the purpose of improving care quality.

The focus of comanagement on improving quality is in line with the founding charge of the hospital medicine specialty to raise hospital care quality.10 In fact, the distinction between comanagement and consultation may be meaningful only if comanagers can work with specialists to implement evidence‐based practice, process improvement, and address quality and cost concerns. But as seen in NPPs and fellows' skepticism of improved quality under comanagement, there is still clearly work to be done to validate this model through measurable improvement in patients' experiences and outcomes. Proving the advantages of comanagement as a platform for practice improvement remains future work.11

Collaborative arrangements create natural tensions related to team function.5 This is seen in the similar proportion of hospitalists and hepatologists indicating desire for final decision‐making authority. Although comanagement evokes assumptions about egalitarian provider interactions involving shared decision‐making and responsibility, it seems to function empirically under hierarchical as well as consensus‐seeking forms of decision‐making. Providers at the top of hierarchical teams typically experience their work as interdependent and collaborative, and report more positive interactions with other care providers.12 Based on the fact that no hepatologists wanted more influence over decision‐making, we assume that hepatologists were the physician leaders for most of the studied comanaged teams. Under situations characterized by high levels of complexity and interdependence, a team governed by a single leader may often be more effective than one governed by shared authority.8 However, even under hierarchical models, a more participatory than supervisory leadership can help avoid alienating partners through a pattern of we decide, you carry it out that is often associated with ineffective leadership styles.1314 In fact, this alienating effect on providers in subordinate roles (ie, NPPs and fellows) may have contributed to the negative perception of the team's function on improving patient care.

This study is limited in the following ways. We did not have 100% participation in the Repeated Surveys. Attitudes and experiences of participants in a single comanagement practice are not representative of all comanaging providers. However, the goal of this studyto collect unique survey data from providers themselves to inform an evolving definition of comanagementis modest enough in scope to not require a generalizable sample. Because this study unearthed differences in expectations and experiences within a single site, they may serve as a lower bound for the extent of differences across and within multiple sites. In addition, comanagement enacted for complex medical patients is not as common as the comanagement of surgical patients. Moreover, comanagement models in academic hospitals may have structural features and priorities not found in community settings. Whether or not these disparate models share enough in common to be categorized under a single rubric is a valid question.

Although the teamwork structure and provider roles within comanagement vary, the practice arrangement's preoccupation with quality can be seen as its defining feature. Limited evidence, to date,1, 1519 and the rapid proliferation of the model, suggest that quality and efficiency advantages can be obtained from an effective implementation of comanagement. As in any team‐based care model, a common understanding of roles and expectations are essential to enhancing teamwork. Our interpretation of the mission of comanagement may further enhance teamwork through an explicit articulation of shared goals.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.