Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”
Anticipate Demand
Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.
That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”
However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.
The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”
Fault Lines
Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.
General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.
Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”
The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.
Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.
Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.