ACADEMIC HOSPITAL MEDICINE: A REESES’ PEANUT BUTTER CUP

Mike Radzienda writes…

Remember that commercial, “Hey, you got your chocolate in my peanut butter!?”   Those two great tastes that go great together…

How about, “With a name like SMUCKERS you know it’s got to be good?”  If one had never eaten Smuckers jelly, one might have guessed otherwise.

Any-hoo…

Last week I read an article entitled “So You Want To Be An Academic Hospitalist?”  I was disappointed and I submit that the article missed an opportunity to make an important point.  Please indulge me and my lame metaphors:

When I was in residency, I didn’t know I wanted to be an academic hospitalist. At that time, before NAIP, or Robert Wachter’s seminal article, my career goal was to practice inpatient medicine in an academic setting. In 1997 I started my job search. There was only one advertised position (thank you Dr. Rudd for the offer, but Palo Alto was too far from home).  Fortunately, my Chairman afforded me an opportunity where I trained and I have been a hospitalist in an academic setting ever since. However, by no means am I an academic.

Unlike the market-driven explosion of hospital medicine in the private sector, the evolution of hospital medicine in academia has been a story of incremental changes and local struggles to adapt.  2003’s ACGME mandate shifted the paradigm of academic medical practice overnight. Once a seemingly endless supply of cheap labor, the trainees who served as the cogs and wheels of every teaching hospital have been relegated to observer-like status.  Then, with patient acuity increasing, stifling urban- payer mixes and large gaps in staffing, enter the academic hospitalists-Knights in modestly priced shoe ware.

Faculty positions once coveted by chief residents, the fellowship trained, or the dual-degreed “triple threat,” are now offered to candidates whose academic credentials and potential for academic productivity are not quite robust.  Open any medical journal and pick from a list of Academic Hospitalist want-ads:

Wanted
Academic Nocturnist

(Rank commensurate with experience)

Really?

As if there is some intellectually stimulating side to convincing the radiology R-2 on-call that your patient needs a CT angiogram while you cross cover 100 tertiary inpatients at 0300 on a Saturday ?  Which senior faculty nocturnist will you choose as your mentor; the one with the R01 grant for studying milk of magnesia versus senna?

So here we are years after the Bell Commission collided with the Oslerian Tradition or, “Hey, you got your 100 years of rigorous clinical training in my malpractice suit.”  If you are a Chair of Medicine, IM Program Director, GIM Division Chief, or a Hospitalist Program Director, you know this was not a tasty combination.  Departments that may have hired one new faculty member every 3years, may now scramble to hire a new class of hospitalists perennially. Turnover remains high relative to other disciplines. Many faculty view HM as a stepping stone rather than a career choice and many programs are predicated on this concept.

The ACGME reforms are a good thing.  As a patient, I would much rather be cared for by a resident who is well rested when I come in with my grabber. Yet, as a HM program director, I want hospitalists in our teaching institutions to be invested, respected, remunerated, and satisfied. Unfortunately, many teaching hospitals do not have the tools and resources to create models of care delivery that not only fill in the gaps, but also add value.

A successful career in academic hospital medicine must mean more than securing research funding and climbing the traditional rank and tenure ladder. The foundation for any academic program is a solid clinical operation with thoughtful practice management.  Without sound clinical operations, retention is unlikely. With a well staffed, thoughtful model that affords professional growth, satisfaction, and reasonable remuneration, an academic HM practice may begin to develop the other facets of its mission. We should not allow Academic HM practice to be the square peg forced into the round hole of traditional academia; this approach is anathema to the purpose of the movement.

So the next time you read the wants ads, ask yourself, “With a name like academic hospitalist, do I know it’s got to be good?”

Happy New Year to All.

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