How to Navigate Hospital Medicine

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How to Navigate Hospital Medicine
Each career path within hospital medicine offers distinct responsibilities, opportunities, and rewards. One of the biggest decisions you'll make as a hospitalist is whether to enter an academic or a community-based hospital medicine field-but there are additional factors to take into account. Here's an overview of the career paths within these two areas that may help you with your decision.

Only a small percentage of hospitalists go into academic jobs, and residents are–obviously–most familiar with these choices.

"[The environment] is familiar to you, and you're able to grow professionally because people are always asking you questions," says Sanjay Saint, MD, MPH, hospitalist and professor of internal medicine at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School. "The opportunity to be around learners–residents and medical students–is very exciting to residents."

There are other reasons you may prefer academic over community-based hospital medicine. "The types of patients you treat are different," says Dr. Saint. "They may be more complicated, and thus you can improve your clinical skills. Also, there's prestige in being associated with an academic medical center. That appeals to some people." The rigorousness of the schedule varies with the institution. "Theoretically, you have residents, so you don't have to take calls," explains Dr. Saint. "But when you're on, say, for a month there's often no attending coverage on weekends or holidays." Hospital medicine work in an academic setting falls into four categories:

Hospitalist Clinician-investigator. "These hospitalists typically spend the minority of their time doing clinical work–maybe 20% to 40% of their time," says Dr. Saint. "The rest is spent developing their research agenda, applying for and obtaining grants to fund their research. The investigative focus is usually inpatient-oriented to provide synergy between their clinical work and their research." This track typically leads to tenure, and usually requires some type of fellowship.

Hospitalist-educator. "There are a large number of these positions in academic medical centers," says Dr. Saint. "These hospitalists spend about 80% of their time seeing patients and teaching residents and medical students."

Typical hospitalist-educator activities include ward attending, medical consultation, and preoperative evaluations. "They spend about 20% of their time doing some type of scholarly activity, whether writing articles or developing educational curricula that can be disseminated," estimates Dr. Saint.

Hospitalist-educator is usually a non-tenured position and these academicians are promoted primarily based on their clinical expertise and perceived skills as teachers. You don't need to have a fellowship for this position; usually, the hospitalist director will hire individuals from his or her program–often a former chief resident.

Hospitalist-clinician. "These hospitalists primarily focus on patient care," explains Dr. Saint. "A lot of them have been hired recently because of the limits on work hours for residents. There is minimal teaching and scholarly activity."

Often, people do this for one or two years between residency and a fellowship, or to pay off school loans.

Hospitalist-administrator. "A major portion of their day is spent on administrative tasks," says Dr. Saint. "They may run the hospital medicine program, or have educational administrative tasks, like residency directors." However, he warns, "a resident isn't going to go straight into one of these positions; you have to pay your dues first. But this can be an opportunity to think about for the future."

What is the job market like for these academic positions? "There are huge opportunities for residents wanting to become hospitalists, regardless of which track they want to follow," says Dr. Saint. "There are only a handful of clinician-investigators in hospital medicine now, and I see tremendous growth in this field. There's also a growing need for hospitalist-clinicians because of the restrictions imposed on the workweek [for residents]. And as the number of hospitalists grows, there will obviously be a need for more hospitalist-administrators. Of course, there will always be a need for hospitalist-educators–but many are already in those roles."

The first thing to realize about community-based hospital medicine is that there are various employers involved.

"Programs will have different mandates; a lot depends on the financial drivers," says Sanjiv Panwala, MD, hospitalist at Providence Medical Center, Portland, Ore. "If you're paid by the hospital, your priorities will be theirs: coverage of uncovered patients, shorter length of stay, etc. It trickles down."

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, agrees. "It's important to understand who the employer is and what their values are," he says. "Is it the hospital or a local, regional, or national practice? If you're employed by a hospital, you may be one of several employed specialists." That can impact what types of clinical work you handle.

Regardless of whom you work for, says Dr. Williams, "The biggest differences [from an academic institution] are a much greater focus on patient care, and the fact that community-based groups change and evolve more quickly than academic groups."

But there can be more to community-based hospitalists than direct patient care. "Ask if the job is limited to clinical duties or if there are ways to branch out and expand, maybe by becoming a medical director for a hospital or by designing quality programs," suggests Dr. Williams.

Cara Steinkeler, MD, a hospitalist at Kaiser Permanente Sunnyside Medical Center, Clackamas, Ore., worked in private practice before she signed on with managed-care giant Kaiser. "Overall, the schedules–in terms of number of days per month and shifts–are pretty similar" for managed care and private practice, she says. "In terms of quality of life, they're also about equivalent."

The difference may be in how hospitalists spend their time. "I'm relatively isolated from the business of medicine," says Dr. Steinkeler. "We're able to concentrate on treating patients. When I was in private practice, I'd spend 10 or 15 hours a week doing my own coding and billing; here, we [now] have coding experts that do that."

Dr. Steinkeler's group is primarily salary-based, so she isn't tied to productivity. While the salaries may not always be as high as other hospitalist options, there are trade-offs. "I know that the starting salaries for hospitalists in private practices in Portland were a little higher than for HMOs," says Dr. Steinkeler. "The financial payoff for working here is really when you stay long enough be vested; it's in the benefits. But we tried to rectify that [starting salary discrepancy] because we were having trouble hiring."

Keep in mind that hospital medicine programs can vary widely, for both academic and community-based institutions. "Program differences are based on the size of the program," explains Dr. Panwala. "In tertiary care centers, you won't do much ICU work, but in a small or medium-sized hospital it's very different. You can basically be the ICU doc."

The plus side of working for a larger hospital medicine group is flexibility and opportunity for career growth. Dr. Steinkeler highlights another benefit: "One good thing about working in a large group is the flexibility," she says. "A large group has the ability to flex around people's needs, so you can cut your hours or get time off if you have kids or aging parents."

This basic information on the various employment options within hospital medicine should give you a good starting point in choosing the career path you'd like to take. Your decision, or preliminary preference, will influence how you prepare for, and go after, your first position as a working hospitalist.

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