Step 2: Man Cannot Live by wRVUs Alone
An extension of this idea is that academicians need time for scholarship. In fact, academic productivity cannot be measured in wRVUs alone. Don’t get me wrong; hospitalists need to support their salaries and see lots of patients. But teaching the next generation, developing and disseminating knowledge, and generating a promotable academic portfolio takes time—time that can’t be shoe-horned into 200-plus busy clinical shifts a year. This is supported by evidence showing that more than 20% of protected non-clinical time was one of the biggest predictors of academic productivity.2
Five thousand wRVUs? Way too much. Four thousand? Getting warmer. Three thousand? Try a little lower. I’d go out on a limb and say the right number is slightly below 3,000 wRVUs.
I suspect this will raise some eyebrows among hospital administrators who fund these programs—and I welcome the letters. But before you pick up your pen, consider this: What is the value of educating our future physicians (something most teaching hospitals are funded to do through graduate medical education dollars), discovery, scholarship, hospital quality improvement (QI), and sustainable faculty careers? Academic hospitalists have decided to value it with a pay cut. Are our administrators willing to make a similar sacrifice?
Step 3: Culture of Scholarship
Protected time comes with a responsibility to produce. Discovering, publishing, speaking, and presenting are hard work—so hard that the default of not doing it presents an all-too-often-enticing option. This in part explains why most academic hospitalists have not published a first-author, peer-reviewed paper (51% have not), given institutional medical grand rounds (74%), or presented at a national meeting (75%).1
This is where cultivating a group culture of scholarship replete with expectations (# of publications/year), opportunities to present work (hospitalist Grand Rounds), faculty development, mentorship and institutional support (financial commitment and time to teach) are paramount.
Step 4: Academic Currency
Let me emphasize that last point. The majority of academic hospitalists lack formal fellowship training and, therefore, are not going to be funded or promoted based on research outputs. In fact, more than 90% of hospitalists will be promoted (or not) through the clinician-educator pathway. That means our academic currency is teaching and curriculum development.
That’s why the majority of academic hospitalists spending the majority of their time on non-teaching services is a major problem. It’s akin to an eternally unfunded researcher trying to get promoted as a clinician-investigator. It’s not going to happen.
Duty-hour restrictions, growing hospital services, PCP exodus from our hospitals, and the growth of comanagement are driving further hospitalist expansion in teaching hospitals. This means more mouths competing for a shrinking teaching pie. I don’t have the solution, but I suspect that those clinician-educators spending less than 25% of their time with learners will find it difficult to be sated, successful, and promotable in academia.
Step 5: Mentorship
Mentorship unquestionably is tied to publications, presentations, grant funding, job satisfaction, and, ultimately, academic promotion. Yet only 42% of academic hospitalists report having a mentor.2 Of those with a mentor, the vast majority spend less than four hours a year with their mentor.2 I can identify no more obvious and urgent problem to solve in academic HM.
Step 6: Job Structure
The single most powerful predictors of burnout and low satisfaction are a lack of work/life balance, autonomy, and control over one’s work environment. In fact, control over work schedule (odds ratio 5.35) and amount of personal time (OR 2.51) were the biggest predictors of burnout for academic hospitalists. Similarly, control over work schedule (OR 4.82) and amount of personal time (OR 2.37) predicted low satisfaction.1 The bottom line is that flexibility, autonomy, and control are essential components to academic fulfillment.