Hospitalists often are the most knowledgeable inpatient clinicians with regard to a wide range of health care industry issues. These include comprehension of the payer/insurance regulations regarding medication formularies, utilization review requirements, and other care policies. Their expertise may extend to knowledge of state and federal regulations, public health initiatives, and recently enacted or pending health care legislation. Finally, hospitalists also are often conversant in the field of health care economics, especially regarding the financial impact on hospitals of reimbursement policies, legislative initiatives, technology, etc.
The fifth sphere of hospitalist expertise combines several knowledge domains. Individual hospitalists have specialized expertise in particular fields related to hospital medicine. Some hospitalists, mostly affiliated with academic institutions, are researchers who may develop research protocols, gather data, perform statistical analyses, and write papers that may potentially become the basis of improved patient care. Other hospitalists are exceptionally experienced in management/leadership. A hospitalist may be highly qualified to manage projects (e.g., computer-based physician order entry systems, throughput initiatives, etc.),or a hospitalist could be a strategic thinker who is viewed as a key clinical member of the hospital’s management team.
As a growing specialty, hospitalists have established a proficiency in a range of disciplines and intellectual domains. They are well positioned to assume the role of educator in the hospital environment. Given the exceptional knowledge and skills needed to be a hospitalist, the Society of Hospital Medicine (SHM) is pursing an effort to standardize education and lend greater credibility to the hospitalist profession. The “core curriculum” project is currently formalizing training that will provide a solid foundation for effective clinical practice in the field of hospital medicine.
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Table 1: Results of Research on Hospitalists as Educators
Dual Educational Tracks
As depicted in Figure 1 below, medical education activity and the ways in which knowledge is imparted fall into two categories: formal and informal. Although some overlap may occur, there are distinct characteristics attributable to both classifications.
“Formal”
Formal education refers to the traditional “teacher-learner” roles in medicine. The learner can be a medical student, resident, or fellow. Education is typically transmitted from teacher to learner (as depicted in the diagram by a solid line), with some reciprocal feedback from the learner to the teacher (dotted line). It should be noted that as the importance and value of hospital medicine programs gain recognition, fellowship programs focusing on this specialty have been established. As of August 2004, eight active hospital medicine fellowship programs exist in the United States: three in California, two in Minnesota, and one each in Ohio, Illinois, and Texas. There are also pediatric hospital medicine fellowship programs in Boston, Washington DC, Houston, and San Diego. Each program enrolls one or two fellows annually (4).
Formal education can take place in both academic medical centers and community hospitals. By definition, academic medical centers provide supervised practical training for medical students, student nurses, and/or other health care professionals, as well as residents and fellows. In many academic medical centers throughout the country, hospitalists are emerging as core teachers of inpatient medicine. A prime example is the University of California, San Francisco. In 2002, 15 faculty hospitalists served as staff for approximately two-thirds of ward-attending months, as well as all medical consults (5).
By the same token, community hospitals that have residency programs also incorporate education to some degree into their daily operations. Today, medical education places a significant burden on residents and on the professionals charged with teaching students to absorb and understand vast amounts of science and medical information. On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) revised the regulations governing the number of resident duty hours. These changes have forced residency programs to find viable options for imparting the required knowledge and hands-on experience to residents in fewer hours. Many consider hospitalists, by virtue of their “superior clinical and educational skills,” as representative of “the solution to the residency work duty problem.” In addition to providing excellence in teaching, hospitalists, known for their “superior clinical and educational skills,” may lead the way in creating and leading a clinical research agenda, which presents as the ultimate pedagogical experience (6).