Published in the August 2015 issue of Today’s Hospitalist.
HOSPITALIST Michael Janjigian, MD, who directs inpatient general medicine at New York’s Bellevue Hospital, joined the faculty of NYU School of Medicine 10 years ago. Although he spends most of his time as a clinician administrator, he’s always wanted to be active in research, and he has several publications to his credit. He’s currently working on a half-dozen other projects focused on areas like readmissions, physical diagnosis education and curriculum development.
But because he did no subspecialty fellowship, Dr. Janjigian says he never learned the ropes of basic research. He feels that lack of formal training puts him at a big disadvantage.
“You come out of a traditional categorical residency program very intimidated by the whole concept of research,” Dr. Janjigian says. “I feel I’m always behind my peers who have done fellowships, including in general internal medicine, in terms of turning an idea or project into an actual study.”
What do physicians who’ve completed fellowships learn that he hasn’t? According to Dr. Janjigian, the list includes trial design and methodology, when to apply for IRB approval, and what types of grants exist and how to apply for them.
And formal training would have helped him connect with mentors. He says that NYU has done a good job over the past 10 years developing a research program that includes a “brain trust” and resources to support inexperienced faculty. But the program “like many other academic hospitalist programs, he believes “”has not yet developed that level of seniority and depth in research in topics related to hospital medicine,” Dr. Janjigian says.
As a result, the majority of hospitalist scholarship in his program and elsewhere often consists of presenting clinical vignette and research abstracts at regional or national meetings. “Turning those posters into an actual publication in a peer-reviewed journal is still challenging, despite all the resources I have.”
And in spite of his 10 years of experience, Dr. Janjigian says he often seeks advice from more established researchers when mentoring junior faculty on research topics. “I’m able to serve as a resource for many aspects of advancing a career as an academic hospitalist,” he explains. “But I still require a lot of mentoring myself.”
Academic hospital medicine has made great strides in administration, education and patient safety. But the academic workforce is still so young and the clinical demands are so high that “research has been sort of the stepchild for a long time,” says Stephanie Taylor, MD, MMS, who until recently directed a hospital medicine clinical research program at the University of South Florida (USF) in Tampa.
Many academic hospitalists who want to do some research find themselves caught in a vicious cycle: They don’t have the protected time to devote to research, but they don’t have mentors to help them secure grants to buy protected time.
And while many academic hospitalists are not interested in becoming full-time investigators themselves, they do want the field to have a much broader base of investigation. They would also like a chance to earn the respect and advancement opportunities that research affords.
A struggle to find mentors
Like Dr. Janjigian, Dennis Chang, MD, a hospitalist at New York’s Mount Sinai Hospital and an assistant professor, never completed a fellowship. While he’s racked up many published studies, he says it took him years to develop the research skills he needed.
Dr. Chang notes that he’s made plenty of connections with physicians in IT and administration, but mentors “or a lack thereof “remain his No. 1 problem. “Even associate professors in hospital medicine haven’t done a ton of high-level research because there just aren’t many research mentors who are hospitalists,” Dr. Chang points out.
Another big problem: scheduling. Dr. Chang says that 50% of his time is protected for running the third-year clerkship at Mount Sinai, but that often doesn’t leave a lot of time for research. “It’s hard to get consistency, which is going to work on this part of my research every week,’ but you don’t have that luxury.”
Those kinds of challenges take a toll. A report from an academic hospital medicine summit published in 2009, for instance, pointed out that hospitalist researchers had high turnover, few funding sources and “little recognition of quality improvement as a promotable/testable activity.”
But not all the data on hospitalist researchers is so glum. A survey on research and publication trends in the March 2014 issue of the Journal of Hospital Medicine found that between 2006 and 2013, the number of published studies led by hospitalists increased five-fold.
The bad news was that only five centers across the country produced nearly half of those publications. And survey respondents still complained about a dearth of mentors and funding.
“Academic hospital medicine appears to lag behind some subspecialties in terms of research and publication, although there have not been a lot of comparisons made,” says lead author Amy Munchhof, MD, PhD, an academic hospitalist at Eskenazi Hospital and Indiana University School of Medicine in Indianapolis. “Survey responses pointed to hospitalists struggling to identify mentors to enter into research and to subsequently publish.”
Shrinking research dollars
As a career path, academic hospital medicine “has definitely stabilized,” says Thomas McGinn, MD, a full professor and chair of medicine at Hofstra-North Shore LIJ School of Medicine in Hempstead, N.Y., and one of the authors of the 2009 summit report. But “if you look across the top 50 medical schools at the grant portfolio in comparable departments or divisions, hospital medicine is going to be ranked very low.”
Part of the problem, he points out, is funding. Research dollars from the NIH, the National Science Foundation, and the Centers for Medicare and Medicaid Innovation are shrinking, while the House of Representatives this summer proposed legislation that would zero out the AHRQ, a major funder of hospitalist research.
“Funding dollars are becoming harder to get,” Dr. McGinn explains. “Without a long track record and senior physicians, you’re not going to be competitive.” And while hospital medicine in the past decade has produced a stellar group of nationally recognized investigators, “the fact that I can name most of them is probably not a good sign.”
Where hospitalists have made big research gains, Dr. McGinn adds, is in quality improvement. But the impact of those projects is “much harder to quantify,” he says, “and it remains a struggle to have quality improvement recognized as ‘academic currency.’ Those are not what we consider traditional peer-reviewed projects that allow faculty to be promoted.”
One model put forward to help hospitalists “particularly those without fellowship training “connects established researchers with subspecialist partners. University of Michigan, for instance, has a formal program, known as the Specialist Hospitalist Allied Research Program (SHARP).
“We pair up a clinically oriented hospitalist with a subspecialist in a particular field and a project manager who can help them,” says Sanjay Saint, MD, MPH, a clinical investigator on several federally-funded projects. Dr. Saint is chief of medicine at the VA Ann Arbor Healthcare System and the George Dock professor of internal medicine at the University of Michigan Health Systems. He explains that the SHARP program provides the support those hospitalists need “to make sure that the IRB approval or the statistics won’t be a deal-breaker for them.”
That’s a very different track, than clinical investigators typically take. (See “‘Capital R’ and ‘small r’ researchers“.) “We tend not to protect too much of these hospitalists’ time, so they still have to generate their salary based on clinical revenue,” says Dr. Saint. “Our expectations are that they’ll co-author one or two papers a year, not the four or five we expect from tenure-track hospitalist investigators.”
Such a subspecialty partnership model may be viable in top-tier centers where you’re surrounded by subspecialists with NIH funding, says Dr. McGinn. But in smaller facilities, that model may not work.
“Once you get below the top 25 medical schools,” he says, “the funding just plummets. There’s not a big nidus of infrastructure or major clinical research going on.”
At NYU, Dr. Janjigian says that hospitalist researchers have started collaborating with the department of population health. NYU launched that department in 2012, and it’s now where “much of the research infrastructure resides.”
As for reaching out to subspecialists in his institution: “Subspecialists have to prioritize their own fellows,” Dr. Janjigian says, “and they do not necessarily have the resources to take on other interested parties.” Plus, he adds, “subspecialists’ research interests may not be directly aligned with my own.”
Turning to the ED
Pairing inexperienced hospitalists with subspecialists was the original idea behind USF’s clinical research program, which was launched in 2011.
“But we found that a lot of their research interests were on the outpatient side, with long-term patient follow-up that we couldn’t provide,” says Dr. Taylor. She took a different path and completed a two-year master’s program in clinical research to bring some research expertise to the program. She also forged a partnership with the ED.
“We realized that hospital medicine by itself is sort of an island,” Dr. Taylor explains. “We don’t have a good system to follow up on patients after discharge and track medium- and long-term outcomes. And on the front end, the ED “not the hospitalist “is usually the first contact for patients, so patients may have already received interventions that make them ineligible for a study by the time they reach the floor.”
Partnering with the ED allows hospitalists to screen patients and identify potential subjects as soon as they arrive. One joint study is looking at managing A fib with rapid ventricular rate to see which nodal blocker is more effective.
“The ED is interested in which blocker can get the rate down and get patients out of the ED,” Dr. Taylor says. “We’re interested in how easy it is to convert that medication to oral therapy and how it affects length of stay.”
The hospitalist-ED partnership has had the added benefit of “being looked on favorably by the hospital, which has been more eager to fund it” with protected time and support staff. While none of the group’s 10 academic hospitalists has finished a fellowship or received outside funding, Dr. Taylor says the program has allowed half of them to gain some research experience.
The pecking order in research
That’s important, Dr. Taylor adds, for job satisfaction and faculty retention. It’s also proved to be a boon for her own career.
As of this month, she has moved to Carolinas Medical Center in Charlotte, N.C., where she’s charged with starting a hospital medicine research program. The hospital provides research infrastructure including a medical writer and biostatisticians, and is giving her six months a year of protected research time.
Dr. Taylor is certainly aware of the pecking order in research and the fact that clinical research is deemed more valuable than research into quality, high-value care and cost effectiveness. “But these types of research are certainly necessary,” she says, “and the only real difference between a good QI project and academic research is an IRB.”
Eduard Vasilevskis, MD, MPH, is a hospitalist and staff physician with the Tennessee Valley VA Geriatric Research Education and Clinical Care Center and a member of the Center for Health Services Research at Nashville’s Vanderbilt University. He points out that quality improvement studies are published in high-impact journals.
“But they tend to be multi-site studies done through a collaborative network,” Dr. Vasilevskis says. “Many people start with a single-site study, which is OK. I don’t think that should discourage hospitalists from going forward if they learn something from a single site that could be generalizable.”
But how do you forge those multi-site collaborations? “That kind of network,” he says, “is where having mentors and relationships really come into play.”
What’s good for the field?
Given how many different hats hospitalists wear in academic centers, Dr. Vasilevskis thinks traditional clinical research isn’t the only way any more that physicians can advance.
“It’s increasingly recognized that having a portfolio that includes quality improvement projects, even if they aren’t published, are of value to your hospital,” he says. “The same is true of an education portfolio and of technology.” While publication is still the most traditional route up the appointment ladder, “there are many ways of being locally involved that might help.”
Yet for Hofstra’s Dr. McGinn, the issue isn’t just about career advancement. “I get a little nervous that the field has so much in the way of one-off quality research projects and so few randomized multi-center trials,” he says. “There’s a spectrum of research in terms of the validity and exportability of results, and people doing research need to be exposed to larger trials.”
Mount Sinai’s Dr. Chang agrees. “If we want hospital medicine to be viewed around the country as a field, we need those clinical investigators bringing in funding to hospitals,” he says. “That is a big part of the power structure of an academic center.”
He would like not only more full-time investigators, but to have them in many more centers around the country. “I’d like to see a few clinical investigators at our hospital,” he notes. “They could then mentor even small research projects and help get them going.”
At the same time, says Dr. Chang, the issue of hospitalist research underscores how quickly the field has evolved. When he started working as a hospitalist in 2006, “a lot of the talk was about making sure we weren’t just super residents,” he says. “Now, it’s about how to develop more clinical investigators. That’s a pretty amazing problem to have compared to where we started.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
WHILE MANY ACADEMIC HOSPITALISTS struggle to get their research projects off the ground, a handful of centers have emerged as hotbeds of hospital medicine clinical research.
One is the University of Michigan in Ann Arbor, where Sanjay Saint, MD, MPH, helps groom other hospitalists who want to forge a research career.
“To be taken seriously by other internal medicine physicians, there needs to be a scientific component to what we do,” says Dr. Saint, chief of medicine at the VA Ann Arbor Healthcare System and the George Dock professor of internal medicine at the University of Michigan. “Otherwise, we run the risk of being viewed as primarily a service-oriented discipline like emergency medicine. And the coin of the realm within academia is peer-reviewed research in high-impact journals and grants from federal agencies.”
But becoming a serious investigator, Dr. Saint says, is “very difficult without doing an intensive research-based fellowship. For people who want to be a ‘capital-R’ researcher, I tell them that we will invest in them, but first they have to invest in themselves by undertaking the necessary training.”
That training must include “the right type of fellowship,” he explains, one that’s research-heavy. Dr. Saint finished a two-year Robert Wood Johnson clinical scholars fellowship in which he concurrently received a master’s in public health.
For physicians with the right training and ambition, “We give them protected time for several years until they get a career development award or independent funding,” Dr. Saint explains. The university also provides researchers with a robust infrastructure to make research easier, with access to project managers, research associates, and biostatisticians, and assistance with IRB review and submission.
“On average,” he says, “we invest about a half-million dollars in a research-oriented hospitalist who is on a tenure track.” Such hospitalists also have their own mentorship committee, which meets several times a year.
Dr. Saint notes that “small r” hospitalist researchers at the university “who typically aren’t fellowship-trained “may be able to serve as co-investigators on federally funded grants. The university’s Specialist Hospitalist Allied Research Program (SHARP) pairs up hospitalists with subspecialists, all with research resources.
But hospitalists who want to be included in the SHARP program usually need “a fire in their belly,” Dr. Saint says. “We choose them very carefully, and they have to have shown that, as a resident or chief resident, they were able to publish a case report, a systematic review or a clinical problem-solving exercise. We look for physicians who have gone above and beyond.”
Dr. Saint also brings “small r” researchers into his patient safety enhancement program. “I’ll put them on a grant and see how invested they are,” he says. “But you have to be a closer. If you take that opportunity and run with it, there will be more opportunities.”
Another research avenue: getting involved in the multihospital consortium launched by a grant from the Blue Cross Blue Shield of Michigan Foundation to develop patient-safety best practices. “Now, there are hospitalists at community hospitals in the state who have some support for data collection,” Dr. Saint points out. “They can be involved in writing manuscripts and potentially presenting findings at scientific meetings.”
For its own hospitalists, the University of Michigan takes those presentations seriously. Several months before the abstract deadline for the Society of Hospital Medicine’s annual meeting, for instance, senior faculty “pressure-test” abstract ideas, vetting them and editing the abstracts.
“We’re very intentional and mindful about this,” says Dr. Saint. “It’s one reason why the University of Michigan has so many abstracts at SHM.” It helps, he points out, that Scott Flanders, MD, who heads the hospital medicine program at the university “spends a lot of his time ensuring that the hospitalists are involved in scholarly activities.”
AT THE UNIVERSITY OF CHICAGO, Dana Edelson, MD, is surrounded by other hospitalist researchers who, like herself, devote three-quarters of their time to research, often backed by federal funding.
But Dr. Edelson has scored a first among her hospitalist colleagues: Her research has been turned into a commercial product that is on the market.
The product is eCart, a tool that Dr. Edelson and her colleagues developed to predict imminent cardiac arrest, ICU transfer or death. The electronic algorithm relies on more than a dozen data points, including vital signs and lab results, to determine a patient’s risk.
It grew out of five years of Dr. Edelson’s research funded by an NIH grant. That work began during her two fellowships: a one-year stint in resuscitation science and a two-year hospitalist scholar fellowship that included a master’s in health studies. She completed both fellowships at the University of Chicago.
“I came for med school,” Dr. Edelson says, “and I never left.”
A key component of taking the product to market was the university’s tech transfer arm, the Center for Technology Development & Ventures. The center helped Dr. Edelson found a company “Quant HC “for which she is CEO.
The center is also helping Quant HC license the algorithm to other companies. eCART is already available through Apertiva, an analytics software platform developed by a Chicago-based company. eCART will also soon be incorporated into different monitoring devices and hospital EHR systems.
In addition to help from the university, Dr. Edelson says her company got a major boost from MATTER, a health-tech start-up incubator launched in Chicago this year.
“Chicago has watched what’s happened on both coasts and realized there are a lot of resources in the city that could be put to great use,” she says. “A key metric to me is that Chicago is uniquely positioned to be a hub for health tech.”
Her next research priority is to hone eCART to identify patients at low risk for arrest. “Our strategy is to focus on the science,” she says, “and to collaborate with partners already in the marketplace who can do the marketing.”
But while she intends to remain an academic, “one of my frustrations has been around the time it takes to go from a research idea to actually changing practice,” Dr. Edelson says. “If commercializing research is a quicker way to get it into people’s hands, then I’m thrilled to do it.”