Over the past three decades, there has been the inception and continued development of the field of hospital medicine. The reasons for this are several and include the career preferences of physicians themselves, increasing demands and financial pressures on physicians in the ambulatory setting, and the need for hospitals to maximize efficiency and patient throughput, all while maintaining and augmenting mechanisms to document the quality of care and payment justification. Concomitant with this trend was a parallel movement of many diagnostic and therapeutic procedures to the ambulatory setting, narrowing the spectrum of diseases routinely admitted for inpatient hospital stays.1,2

Hospitalist programs in academic medical centers have also responded to changes in the regulations surrounding the work hours of resident trainees, in many cases creating “non-teaching” hospitalist services, at times in parallel to teaching services also managed by hospitalist physicians. A 2010 survey noted that most Internal Medicine departments have hospitalists in teaching and educational administrative roles.3 According to studies, residents and medical students have embraced these changes, reporting improved medical education from efficient clinicians leading clinical teams, and providing teaching and lectures.4 It is also reasonable to argue that educating trainees on efficiently using hospital resources is an increasingly important component of medical education.

The patient throughput requirements and Centers for Medicare and Medicaid Services (CMS) admission level of care guidelines have necessitated reductions in patient-learner contact time. Moreover, the transition of tests and procedures to the ambulatory setting has limited trainees’ direct exposure to these important components of diagnosis and therapy. Hospitalists who spend all or part of their effort involved in educational activities such as didactic medical education, hospitalist electives for 4th-year medical students, or offering training sites for allied health professionals now have obligations to remain current in aspects of medicine that they may not see on an everyday basis as well as the routine aspects of inpatient hospital medicine.

The importance of this major role requires an evolution in mindset and the adoption of strategic initiatives to ensure ongoing success as clinical educators. Much of hospital medicine’s future in teaching hospitals, especially within the large academic medical centers, will depend upon developing vigorous faculty development programs to enhance teaching skills, clinical work, and clinical research. An increased emphasis on the culture of learning and embracing the required parameters will serve the needs of adult learners in the inpatient environment and buttress the professional goals and aspirations.5,6

Learning and keeping up with current medical information enhances patient care and reduces preventable readmissions, thereby enhancing operational excellence. Aligning ongoing learning processes with the organizational goals for hospitalists will enhance both teaching and non-teaching services. Among other things, indecision and/or unwarranted consults can be minimized, resulting in reduced inpatient length of stay. Advancement of educational goals that improve operational metrics should be embedded in all hospitalist programs.

Organizational processes should be instituted to facilitate learning. In some programs, monthly clinical meetings for case discussions enhance the dissemination of current medical knowledge and promote group cohesion. Some specialties, such as Endocrinology and Rheumatology, have become increasingly outpatient-based, resulting in diminished interactions with residents/students in the hospital setting. Hospitalist clinical education meetings that provide a forum for these invited specialists to provide updates on pertinent topics will better equip hospitalists to provide educational guidance and oversight of learners in the inpatient setting.7

The 2018 State of Hospital Medicine Report on Adult Hospitalist Services in academic programs showed that 53% of hospitalists’ activities were on the non-teaching service.5 Other opportunities should be explored to create more options for educational activities on these non-teaching services. The establishment of hospital medicine elective programs for residents and students, making programs available as sites for inpatient rotations for Allied Practice Professional students (NPs and/or PAs), active involvement in divisional, departmental, regional, and national educational (Society of Hospital Medicine) programs are a few examples.5

A learning culture requires ongoing evaluation of individuals and the division’s goals (Figure 1).8 Compensation plans for hospitalists should include requirements for tangible academic activities that are indicators of ongoing learning. RVU-based plans without due recognition for educational endeavors stifle academic work and clinical excellence. In addition to teaching evaluations by residents, medical students, and nurse practitioner/physician assistant students, evidence of publications, presentations at scientific meetings, and other academic activities should be recognized and rewarded.8

Figure 1
Figure 1.Developing a Learning Culture

Clearly, support for academic activities is essential to achieving both academic and organizational goals. This support can come in various forms: time for academic activities and sponsorship for presentations at regional, national, and international meetings. We believe that harnessing the synergy between academic activities and organizational goals will yield the required return on investment in a culture of learning. In evaluating metrics for this return on investment, it will be important to include the proper balance of measures (inpatient length of stay -LOS, patient satisfaction, employee retention, clinical outcomes).

Here at Brown, we started the Journal of Brown Hospital Medicine three years ago, a venture that has provided professional advancement opportunities for faculty and trainees alike. We are proud to have achieved our goal of PubMed Central indexing and look forward to continued growth in the years to come. To continue meeting the challenge of inpatient clinical education, robust programs to encourage learning and enhance academic work in both teaching and non-teaching hospitalist services must be developed. The ensuing benefits of this learning culture include strategic development of operational capabilities, enhanced productivity, recruitment and maintenance of talent, and increased morale, motivation, and satisfaction.

Author Contributions

All authors have reviewed the final manuscript prior to submission. All the authors have contributed significantly to the manuscript, per the International Committee of Medical Journal Editors criteria of authorship.

  • Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND

  • Drafting the work or revising it critically for important intellectual content; AND

  • Final approval of the version to be published; AND

  • Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosures/Conflicts of Interest

The authors declare they have no conflicts of interest

Corresponding Author

Kwame Dapaah-Afriyie, MD
Professor of Medicine, Clinical Educator
Warren Alpert Medical School at Brown University
Division Director
Division of Hospital Medicine
The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906