E D I T O R I A L

Thomas McGinn, MD, MPH

Mount Sinai School of Medicine, Mount SinaiMedical Center, New York, New York

Helping Hospitalists AchieveAcademic Stature

A ccelerating the development of clinical research in academichospitalist programs is a worthwhile goal if pursued with

clarity, objectivity, and a thorough understanding of the processand its implications. In their articles, Flanders et al.1 and Wrightet al.2 identify major barriers to growing academic hospitalistprograms. These barriers include the need for protected time,the shortage of trained research faculty, the lack of infrastruc-ture, and the limited availability of senior mentors. Both Flan-ders et al. and Wright et al. offer smart and innovative ways ofaddressing these issues. However, building an academic programfrom the ground up is more complex and challenging than itmay seem at first glance. It takes time, patience, creativity, diplo-macy, and the ability to recruit collaborators and advocates whoare willing to share infrastructure and resources.

Although both articles add significantly to the discussion ofstrategies for creating an academic hospitalist program, they areunclear about the definition of academic in this context. Theterm academic is often misunderstood to be synonymous withresearch. However, research is just one component of an aca-demic program, which also includes education, quality improve-ment (QI), administration, and program development. It may behelpful, therefore, to replace academic with scholarship, whichcan be defined as a process that involves peer review and disse-mination of ideas at local, regional, and national levels. Scholar-ship also goes beyond research, encompassing education andother areas such as QI. Although academic programs are notnecessarily involved with funded research, there is usually an ex-pectation of peer review, through either presentations at regionaland national meetings or publication. For the purposes of thisdiscussion, the term academic hospitalist program will bedefined broadly to include any program affiliated with a univer-sity that is involved in the teaching of residents and medical stu-dents and whose faculty is required to participate in apromotions process.

All members of an academic division should be expected toparticipate in scholarship, whether it is education, QI projects,or research. If there is a strong expectation that traditionalNational Institute of Health (NIH) funded research will takeplace, this expectation must come with sufficient resources.Without infrastructure for research and investment in researchfaculty, procuring NIH funds for research is not a reasonable ex-pectation. Organizers of hospitalist programs currently withinacademic divisions of general internal medicine should considerways to better integrate programs into the existing researchinfrastructure in their divisions. For either freestanding hospital-ist programs or programs within academic divisions of generalinternal medicine, investments in infrastructure and faculty are

ª 2008 Society of Hospital Medicine 285DOI 10.1002/jhm.341Published online in Wiley InterScience (www.interscience.wiley.com).

needed to nurture this area of research and buildan academic focus in hospital medicine. However,if obtaining NIH research funds is not the expec-tation and resources are not available for hospital-ists or for any other division or department at thatinstitution, then academic expectations shouldfocus on other pursuits. Examples include partici-pation in the education and QI initiatives.

For programs with expectations of bothfunded research and other scholarship, a success-ful program will most likely include a small coreof skilled clinical researchers working closely withwell-trained clinical educators, all of whom areinvolved in scholarship. Both clinical educatorsand researchers need to be continuously develop-ing, and to reach their full potential, all shouldhave access to infrastructure that supports theseactivities, including resources such as MPH-levelproject managers, research assistants, databasemanagers, and, most importantly, appropriatementors.

Clinician educators must be both proficientclinicians and dedicated teachers. Ideally, theyshould have strong familiarity with educationaltheory in addition to skills in hands-on teaching.Their responsibilities include mastering the skillsthat students need, staying up to the minute intheir areas of expertise, and serving as role modelsin their attitudes toward patients, colleagues, andtheir work.3 Many hospitalists may not have theseskills when they begin, often fresh out of resi-dency, and will need help developing them.

PROTECTED TIMEProtected time is crucial to the success of any aca-demic program. Finding this time presents a chal-lenge for any clinical group, but the challenge isexacerbated for hospitalists, who face tremendouspressure to serve full-time clinical jobs with littleemphasis on academic elements such as educa-tion, QI, and participation in funded research. Asboth Wright et al.2 and Flanders et al.1 point out,to build a group of well-developed academic clini-cian educators, academic hospitalists not on trackfor funding need to be given adequate protectedtime to participate in committees, sharpen theirteaching skills, develop QI projects that can beconverted to scholarships, participate in research,and present at national and regional meetings.

The requirements of protected time for res-earchers are more challenging than those for edu-

cators. Building a newly funded research unitwithin a hospitalist group, as with any group, willentail hiring fellowship trained faculty with signifi-cant protected time (approximately 80%) to givethem time to obtain funding such as a K awardand eventually become independent investigatorswith RO1 grant funding. Building research unitsrequires support from collaborators with infra-structure and mentors already in place that canbe tapped during the incubation stage of the aca-demic program. For most hospitalist programs,infrastructure and mentors will be found in theirdivisions of general internal medicine.

Protected time should be considered an inte-gral element of academic hospitalist positions—not a perk—as long as the time is used responsi-bly and productively. As both Wright et al.2 andFlanders et al.1 correctly point out, herein lies themajor challenge of creating any kind of academicprogram: How will the program support protectedtime for both educators and researchers? In mostinstances, significant seed money will be neededto support junior faculty over the first few years oftheir careers. It is noteworthy that building afederally funded hospital medicine research pro-gram will be particularly difficult in today’s econ-omy because funding levels at the NIH, Agencyfor Healthcare Research and Quality, HealthResources and Services Administration, and othertraditional funders of clinical research either areflat or have been reduced dramatically.

To many Academic Medical Centers (AMC), itmay not be immediately obvious why a strongAcademic Hospitalist program is in their eco-nomic best interest. Hospitalist programs mayconfront consistently high levels of turnover and ashrinking supply of general internists. The asso-ciated high costs of hiring new, junior facultyinclude the time and effort needed to interview,credential, train, and most importantly build fa-miliarity with the complex systems encountered inmaneuvering through a hospital, especially onewith widespread dissemination of electronic medi-cal records for documentation and order entry.However, hospitalists provided with opportunitiesfor academic development are more likely to stayon the job longer and perform at a higher level,providing convincing motivation for hospitals toinvest in their academic hospitalist programs.Retaining high-quality hospitalists may be one ofthe most cost-efficient methods for an AMC tosupport a hospital medicine program.

286 Journal of Hospital Medicine Vol 3 / No 4 / July/August 2008

STRATEGIES IN ACTIONFlanders et al.1 point to a shortage of well-trainedclinician investigators with a focus on inpatientresearch as a barrier to the development of aca-demic hospitalist programming. They describe astrategy of collaboration with specialty groups.This highlights the importance of collaborationwith more well-established research units as a keyingredient to building a new academic unit.Wright et al.2 describe their mentorship programand how they created protected time for scholar-ship for hospitalists, including supporting men-tors’ time. These examples highlight another keybenchmark of a viable academic program, men-toring, and the importance of ensuring that men-tors have time for this essential effort.

However, it is critically important to remem-ber that ‘‘all politics is local,’’ to quote the late TipO’Neill, long-time speaker of the US House ofRepresentatives. What works in one setting maynot work as well in a different context—hence theneed for creativity and political acumen.

For example, although the specialty-group col-laboration described by Flanders et al.1 may behelpful in one setting, other strategic alliancesmay work on a larger scale and over a longer timeperiod. Most hospital medicine groups are cur-rently within academic divisions of general inter-nal medicine, where infrastructure and mentoringmay already exist for both research and educa-tional scholarship. In those cases, fostering inter-action between the division’s hospitalists and itsresearchers would be a critical first step. The pro-gramming and growth developed in this way canbe leveraged to support ongoing academic activ-ities by hospitalists rather than being limited to asingle project.

In the Division of General Internal Medicineat Mount Sinai, which houses the academic hospi-talists, building research entailed collaborationwith the well-established Departments of Geriat-rics and Health Policy, which had preexistingresearch infrastructure and mentors. At the sametime, we developed a research fellowship programby applying jointly with the Division of GeneralPediatrics for federal grant support. Such diversityof collaboration enhanced our application.

LOOKING AHEADPutting the academic into academic hospitalistprograms is the key to the future of hospital medi-cine. To be successful, one must consider all theissues described in light of available resources andthe local and federal political landscape. As Flan-ders et al.1 and Wright et al.2 emphasize, colla-boration will be the main component for successin the current academic landscape.

Address for correspondence and reprint requests: Thomas McGinn, MountSinai Medical Center, 17 E 102nd Street, Box 1087, New York, NY 10029;Telephone: 212-824-7505; Fax: 212-426-5108; E-mail: thomas.mcginn@mountsinai.org

Received 6 June 2008; accepted 7 June 2008.

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