Missing Voices: What Early Career Hospitalists View as Essential in Hospital Medicine–Focused Education

Ryan E. Nelson, MD; Daniel N. Ricotta, MD; Ali Farkhondehpour, MD; Aram A. Namavar, MD, MS; Alan M. Hall, MD; Brian K. Kwan, MD; Shannon K. Martin, MD, MS

Disclosures

South Med J. 2023;116(9):739-744.

Abstract and Introduction

Abstract

Objectives: Acknowledging that a successful career in hospital medicine (HM) requires specialized skills, residency programs have developed hospital medicine–focused education (HMFE) programs. Surveys of Internal Medicine residency leaders have described HMFE curricula but are limited to that specialty and lack perspectives from early career hospitalists (ECHs) who recently completed this training. As such, we surveyed multispecialty ECHs to evaluate their preferences for HMFE and to identify gaps in standard residency training and career development that HMFE can bridge. The objectives of our study were to describe multispecialty ECH needs and preferences for HMFE and to identify gaps in standard residency training and career development that HMFE can bridge.

Methods: From February to March 2021, ECHs (defined as hospitalists within 0–5 years from residency) were surveyed using the Society of Hospital Medicine's listserv. Respondents identified as having participated in HMFE or not during residency (defining them as HMFE participants or non-HMFE participants).

Results: From 257 respondents, 84 (33%) ECHs met inclusion criteria. Half (n = 42) were HMFE participants. ECHs ranked clinical hospitalist career preparation (86%) and mentorship from HM faculty (85%) as the most important gaps in standard residency training and career development that HMFE can bridge. Other key components of HMFE included exposure to quality improvement, patient safety, and high-value care (67%); provision of autonomy through independent rounding (54%); and preparation for the job application process (70%).

Conclusions: Multispecialty ECHs describe HMFE as positively influencing their decision to pursue a hospitalist career and increasing their preparedness for practice. HMFE may be particularly well suited to foster advanced clinical skills such as independent rounding, critical thinking, and self-reflection. We propose an organizing framework for HMFE in residency that may assist in the implementation and innovation of HMFE programs nationwide and in the development of standardized HMFE competencies.

Introduction

Hospital medicine (HM) is a career destination accessible from multiple different residency training pathways, and an increasing number of generalists are pursuing HM careers.^[1,2] This trend underscores the need for effective, updated programming within residency to prepare trainees for HM practice. Although recent changes in the Accreditation Council for Graduate Medical Education Internal Medicine milestones separate some clinical skills by inpatient and outpatient domain (eg, Patient Care Milestones 4 and 5), a successful career as an academic hospitalist may require additional skills that are not emphasized in traditional graduate medical education (GME).^[3–5] Moreover, adult HM does not require fellowship training to enter the specialty (unlike Pediatric HM), further highlighting the importance of developing comprehensive training for HM careers in residency.

Recognizing this gap, some residency programs have developed HM-focused education (HMFE) curricula as electives, rotations, and/or longitudinal tracks.^[6–9] Existing programming has been described using surveys of residency and HMFE faculty leaders, but lacks the valuable insights and reflections of trainees or early career hospitalists (ECHs).^[10,11] The perspectives of ECHs with recent exposure to HMFE are important for informing curricular design, yet their voices are currently missing in the conversation.

As such, we surveyed multispecialty ECHs to identify needs and preferences for HMFE and to evaluate gaps in standard residency training and career development that HMFE can bridge. We then synthesized these data with existing research to create an organizing framework for HMFE in residency as a tool for medical educators and hospitalist leaders tasked with implementing or improving HMFE curricula at their institutions and as groundwork for developing standardized HMFE competencies.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References
Sidebar

Table 1. Reported prevalence and preferences for clinical, nonclinical, and curricular activities in HMFE reported by ECHs
	Prevalence^a n (%)	Preference^b WAVG (rank)
Clinical
Admit new patients (not holdovers)	31 (83.8)	1.88 (1)
See medicine consults	30 (81.1)	2.63 (2)
Triage admissions to hospital medicine care teams	14 (37.8)	2.82 (3)
Comanage patients with nonmedicine services	26 (70.3)	3.22 (4)
Work in units to which you may not have been exposed	12 (32.4)	3.31 (5)
Receive holdover admissions	16 (43.2)	3.33
Perform common Internal Medicine procedures	21 (56.7)	3.45
Work offsite at skilled nursing facilities or postacute care	8 (8.11)	3.56
Nonclinical
Work on quality improvement or patient safety projects	19 (51.35)	1.95 (1)
Teach housestaff or APPs	15 (40.5)	1.98 (2)
Teach medical students	16 (43.2)	2.02 (3)
Engage in clinical scholarly activity (research, innovations, vignettes)	15 (37.8)	2.06
Curricular
Evidence-based practice in hospital medicine	27 (73.0)	1.8 (1)
Career mentorship	16 (43.2)	2.4 (2)
Value in healthcare (high-value care, Choosing Wisely)	15 (40.5)	2.84 (3)
Patient safety	20 (54.1)	2.88 (4)
Quality improvement	20 (54.1)	3.32 (5)
Billing and compliance	14 (37.8)	3.40
Palliative and end-of-life care	13 (35.1)	3.64

APP, advanced practice provider; ECH, early career hospitalist; HMFE, hospital medicine–focused education; WAVG, weighted average.
^aPrevalence of activities experienced during HMFE training, according to respondents who participated in HMFE (n = 42).
^bPreferences for activities ranked as most important for HMFE training, according to all respondents (n = 84).

Table 2. Most important differences between HMFE training and traditional wards rotations reported by ECHs
Theme/subtheme/description	Representative quotes
Different clinical structures
Higher volume and acuity	"Higher patient volume and acuity, as well as more autonomy in making care decisions, etc."
Enhanced autonomy	"More volume; less time rounding with ward team. More time as either leading rounds/pseudo-attending or just doing high-volume admits/consults."
Nontraditional rounding	"Very different type of rounds, less formal presentation"
One-to-one access to HM attendings	"One on one with an attending, able to focus on clinical autonomy in a way a larger training team can't achieve"
Education
HM-focused topics	"Teaching topics focused on hospitalist topics" "Focus on billing and other real-world problems that you encounter as an independent practitioner"
Unique clinical experiences
Community-based exposure	"This was an experience at a community hospital, which I otherwise would not have experienced (was at an academic center + VA training)"
Consultative, perioperative, and comanagement medicine	"More interaction with surgical services in a consult model, which more closely resembles what I do now." "Participation in medicine consults and perioperative management" "Comanagement"
Triage medicine and rapid response experience	"RRT/code simulation and training built in, triage experience"
Procedures	"Gain proficiency and confidence in common IM procedures"

ECH, early career hospitalist; HM, hospital medicine; HMFE, hospital medicine–focused education; IM, internal medicine; RRT, rapid response team; VA, Veterans Affairs.