Romsai T. Boonyasai, MD, MPH

Although primary care physicians (PCPs) have traditionally treated patients in both ambulatory and hospital settings, many relinquished inpatient duties to hospitalists in recent decades.[1] Little is known about the PCPs who relinquished inpatient care duties or how the transition to the hospitalist model occurred. For example, what are the characteristics of PCPs who change? Do PCPs adopt the hospitalist model enthusiastically or cautiously? Characterizing PCPs who adopted the hospitalist model can help hospitalists understand their specialty's history and also inform health services research.

Much of the interest in the hospitalist model has been generated by studies reporting improved outcomes and lower hospital lengths of stay associated with hospitalist care.[2, 3, 4, 5] Conversely, detractors of the model point to reports of higher postacute care utilization among hospitalist patients.[6] Although these studies usually adjusted for differences among patients and hospitals, they did not account for PCP characteristics. As patients' access to PCPs and their PCP's capabilities are both plausible factors that could influence hospital length of stay (eg, decisions to complete more or less of a workup in the hospital), quality of care transitions, and postdischarge utilization, it is important to determine if PCPs who use hospitalists differ systematically from those who do not to correctly interpret health system utilization patterns that currently are attributed only to hospitalists.[7, 8]

We conducted this study to determine if observable PCP factors are associated with patients' use of hospitalists and to describe the trajectory by which PCPs referred their patients to hospitalists over time.

METHODS

RESULTS

During the 2001 through 2009 study period, between 2252 and 2848 PCPs were associated with at least 20 hospitalized beneficiaries in any single year. Among these, 1172 PCPs were associated with at least 20 hospitalized beneficiaries in every year of the study period. These 1172 PCPs were associated with 608,686 hospitalizations over the 9 years.

Table 1 presents the characteristics of the PCPs who contributed to the cross‐sectional analyses in 2001 (N=2252) and 2009 (N=2387), as well as the 1172 PCPs for whom we had data for all 9 years for the longitudinal analyses. Most PCPs were male, trained in the United States, and were board certified. The average number of Medicare patients seen by these PCPs and number of outpatient Medicare visits went up about 7% between 2001 and 2009.

Figure 1 graphs the percentage of PCPs as a function of what percent of their hospitalized patients received care from hospitalists, and how that changed from 2001 to 2009. For 70.9% of PCPs, fewer than 5% of their hospitalized patients received hospitalist care in 2001. By 2009, the percent of PCPs in this category had decreased to 15.2%. In contrast, in 2001, more than half of the patients for 2.1% of PCPs received hospitalist care, and the percent of PCPs in this category increased to 26.3% by 2009.

Figure 1

The pattern in Figure 1 shows that PCPs' use of hospitalists changed continuously and gradually over time. However, this pattern describes the PCPs as a group. When examined at the individual PCP level, different patterns emerge. Figure 2, which presents selected individual PCP's use of hospitalists over time, shows several distinct subpatterns of PCP practice behaviors. First, there are PCPs whose use of hospitalists was high in 2001 and stayed high or increased over time (eg, PCP A). There also were PCPs whose use of hospitalists stayed low over the entire study period (eg, PCP B). Finally, there were PCPs whose use of hospitalists was low in 2001 but high in 2009 (eg, PCP C). For this last group, the pattern of change in hospitalist utilization over time was discontinuous; that is, most of the increase occurred over a 1‐ or 2‐year period, instead of increasing gradually over time.

Figure 2

Among the 1172 PCPs associated with 20 hospitalized beneficiaries each year in all 9 years of the study period, group‐based trajectory modeling classified their practice patterns into 4 distinct trajectories (Figure 3). Among PCPs in group 1, more than one‐third of their hospitalized patients were cared for by hospitalists in 2001, and this increased to 60% by 2009. PCPs in groups 2 and 3 rarely used hospitalist care in 2001 but increased their use over time. The increase started early in the period for PCPs in group 2 and later for those in group 3. PCPs in group 4 were associated with little hospitalist use throughout the study period.

Figure 3

We constructed a model to describe the odds of a patient receiving care from hospitalists during the study period using patients associated with these 1172 PCPs. After adjusting for patient characteristics, the residual intraclass correlation coefficient for PCP level was 0.334, which indicates that 33.4% of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. When adjusting for both patient and PCP characteristics, the overall odds of a patient receiving hospitalist care increased by 30% (95% confidence interval [CI]: 1.29‐1.30) per year from 2001 through 2009.

There were also significant interactions between year of hospitalization and several PCP characteristics. These interactions are illustrated in Table 2, which stratifies each of those PCP characteristics by 3 time periods: 2001 to 2003, 2004 to 2006, and 2007 to 2009. In all time periods, patients were more likely to receive hospitalist care if their PCP was US trained (US vs international medical graduate: odds ratio [OR]: 1.42, 95% CI: 1.19‐1.69 in 20012003; OR: 1.46, 95% CI: 1.23‐1.73 in 20072009), or specialized in family medicine (family medicine vs internal medicine: OR: 1.46, 95% CI: 1.25‐1.72 in 20012003; OR: 1.46, 95% CI: 1.25‐1.70 in 20072009). Over time, the relative odds of a patient receiving care from hospitalists decreased if their PCP was female (female vs male: OR: 1.91, 95% CI: 1.46‐2.50 in 20012003 vs OR: 1.50, 95% CI: 1.15‐1.95 in 20072009) or practiced in an urban area (largest vs smallest MSA: OR: 3.34, 95% CI: 2.72‐4.09 in 20012003; OR: 2.22, 95% CI: 1.82‐2.71 in 20072009). Although the longest‐practicing PCPs were most likely to use hospitalists in the early 2000s, this effect disappeared by 2007 to 2009 (most vs least years in practice: OR: 1.35, 95% CI: 1.06‐1.72 in 20012003 vs OR: 0.92, 95% CI: 0.73‐1.17 in 20072009).

In terms of PCP workload, patients of PCPs with high outpatient activity were more likely to receive hospitalists care throughout the study period, although the association had decreased by 2007 to 2009 (highest vs lowest outpatient volume: OR: 1.46, 95% CI: 1.30‐1.63 in 20012003 vs OR: 1.32, 95% CI: 1.20‐1.44 in 20072009). In contrast, PCPs with the lowest inpatient volumes became more likely to use hospitalists by the end of the study period (highest vs lowest inpatient volume: OR: 1.05, 95% CI: 0.95‐1.18 in 20012003 vs OR: 0.55, 95% CI: 0.51‐0.60 in 20072009).

The characteristics of PCPs' practice panels also were associated with patients' likelihood of receiving care from hospitalists. PCPs whose practice panels consisted of patients who were predominantly male, white, or with more outpatient comorbidities were consistently more likely to use hospitalists throughout the study period. PCPs with older patient panels were less likely to use hospitalists in 2001 to 2003, but by 2007 to 2009, they were slightly more likely to do so (oldest vs youngest average outpatient panel age: OR: 0.72, 95% CI: 0.64‐0.81 in 20012003 vs OR: 1.15, 95% CI: 1.05‐1.26 in 20072009).

CONCLUSIONS

Prior studies of the hospitalist model have shown that the likelihood of a patient receiving inpatient care from hospitalists is associated with patient characteristics, hospital characteristics, geographic region, and type of admission.[1, 16, 17] We found that PCP characteristics also predict whether patients receive care from hospitalists and that their use of hospitalists developed dynamically between 2001 to 2009. Although many factors (such as whether patients were admitted to a hospital where their PCP had admitting privileges) can influence the decision to use hospitalists, we found that over one‐third of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. In showing that systemic differences exist among PCPs who use hospitalists and those who do not, our study suggests that future research on the hospitalist model should, if possible, adjust for PCP characteristics in addition to hospital and patient factors.

Although this study identifies the existence and magnitude of differences in whether or not PCPs use hospitalists, it cannot explain why the differences exist. We only can offer hypotheses. For example, our finding that PCPs with the most years of practice experience were more likely to use hospitalists in the early 2000s but not in more recent years suggests that in hospital medicine's early years, long‐practicing generalist physicians were choosing between practicing traditionalist medicine and adopting the hospitalists model, but by 2009, experienced generalist physicians had already specialized to either inpatient or outpatient settings earlier in their careers. On the other hand, the decreasing odds of urban PCPs using hospitalists may reflect a relative growth in hospitalist use in less populated areas rather than a change in urban PCPs' practice patterns.

PCPs trained in family medicine have reported less inpatient training and less comfort with providing hospital care,[18, 19] thus it is unsurprising that family physicians were more likely to refer patients to hospitalists. Although a recent study reported that family physicians' inpatient volumes remained constant, whereas those of outpatient internists declined between 2003 and 2012, the analysis used University Health Consortium data and thus reflects practice patterns in academic medical centers.[20] Our data suggest that outside of academia, family physicians have embraced the hospitalists as clinical partners.

Meltzer and Chung had previously proposed an economic model to describe the growing use of hospitalists in the United States. They posited that decisions to adopt the hospitalist model are governed by trade‐offs between coordination costs (eg, time and effort spent coordinating multiple providers across different settings) and switching costs (eg, time spent traveling between the office and the hospital or the effort of adjusting to different work settings).[16] The authors hypothesized that empirical testing of this model would show PCPs are more likely to use hospitalists if they have less available professional time (ie, work fewer hours per week), are female (due to competing demands from domestic responsibilities), have relatively few hospitalized patients, or live in areas with high traffic congestion. Our findings provide empirical evidence to support their division‐of‐labor model in showing that patients were more likely to receive hospitalist care if their PCP was female, practiced in an urban location, had higher outpatient practice volumes, or had lower inpatient volumes.

At first glance, some of our findings appear to contradict our earlier study, which showed that younger, black, male patients are more likely to receive inpatient care from hospitalists.[1] However, that study included patients regardless of whether they had a PCP. This study shows that when patients have a PCP, their PCPs are more likely to refer them to hospitalists if they are older, white, male, and have more comorbid conditions. A potential explanation for this finding is that PCPs may preferentially use hospitalists when caring for older and sicker hospitalized patients. For example, commentators often cite hospitalists' constant availability in the hospital as a valuable resource when caring for acutely ill patients.[21, 22]

Another potential explanation is that despite their preferences, PCPs who care for younger, minority patients lack access to hospitalist services. One large study of Medicare beneficiaries reported that physicians who care for black patients are less well‐trained clinically and often lack access to important clinical resources such as diagnostic imaging and nonemergency hospital admissions.[23] Similarly, international medical graduates are more likely than their US‐trained counterparts to care for underserved patients and to practice in small, independent offices.[24, 25, 26] As hospitalist groups often rely on cross‐subsidization from sources within a large healthcare organization, independent PCPs may have less access to their services when compared with PCPs in managed care organizations or large integrated groups. Viewed in this context, our findings imply that although hospitalists often care for socioeconomically vulnerable patients (eg, younger, uninsured, black men) who lack access to primary care services,[1] they also appear to share care responsibilities for more complex hospitalized patients with PCPs in more affluent communities. Further research may determine if the availability of hospitalists influences racial disparities in hospital care.

Our study has limitations. It is an observational study and thus subject to bias and confounding. As our cohort was formed using fee‐for‐service Medicare data in a single, large state, it may not be generalizable to PCPs who practice in other states, who care for a younger population, or who do not accept Medicare. Our findings also may not reflect the practice patterns of physicians‐in‐training, PCP populations with high board‐certification rates, those employed in temporary positions, or those who interrupt their practices for personal reasons, as we restricted our study to established PCPs who had been in practice long and consistently enough to be associated with 20 hospitalized patients during every year of the study. For example, the lower proportion of female PCPs in our cohort (15.6% in our study in 2009 vs 27.5% reported in a nationally representative 2008 survey[27]) may be explained by our exclusion of women who take prolonged time off for childcare duties. We also did not establish whether patient outcomes or healthcare costs differ between PCPs who adopted the hospitalist model and traditionalists. Finally, we could not examine the effect of a number of PCP factors that could plausibly influence whether or not PCPs relinquish inpatient care to hospitalists, such as their comfort with providing inpatient care, having hospital admitting privileges, having office‐based access to hospitals' electronic medical records, or the distance between their office and the hospital. However, this study lays the groundwork for future studies to explore these factors.

In summary, this study is the first, to our knowledge, to characterize PCPs who relinquished inpatient responsibilities to hospitalists. Our findings suggest that some groups of PCPs are more likely to refer patient to hospitalists, that the relationship between hospitalists and PCPs has evolved over time, and that the hospitalist model still has ample room to grow.

Although primary care physicians (PCPs) have traditionally treated patients in both ambulatory and hospital settings, many relinquished inpatient duties to hospitalists in recent decades.[1] Little is known about the PCPs who relinquished inpatient care duties or how the transition to the hospitalist model occurred. For example, what are the characteristics of PCPs who change? Do PCPs adopt the hospitalist model enthusiastically or cautiously? Characterizing PCPs who adopted the hospitalist model can help hospitalists understand their specialty's history and also inform health services research.

Much of the interest in the hospitalist model has been generated by studies reporting improved outcomes and lower hospital lengths of stay associated with hospitalist care.[2, 3, 4, 5] Conversely, detractors of the model point to reports of higher postacute care utilization among hospitalist patients.[6] Although these studies usually adjusted for differences among patients and hospitals, they did not account for PCP characteristics. As patients' access to PCPs and their PCP's capabilities are both plausible factors that could influence hospital length of stay (eg, decisions to complete more or less of a workup in the hospital), quality of care transitions, and postdischarge utilization, it is important to determine if PCPs who use hospitalists differ systematically from those who do not to correctly interpret health system utilization patterns that currently are attributed only to hospitalists.[7, 8]

We conducted this study to determine if observable PCP factors are associated with patients' use of hospitalists and to describe the trajectory by which PCPs referred their patients to hospitalists over time.

METHODS

RESULTS

During the 2001 through 2009 study period, between 2252 and 2848 PCPs were associated with at least 20 hospitalized beneficiaries in any single year. Among these, 1172 PCPs were associated with at least 20 hospitalized beneficiaries in every year of the study period. These 1172 PCPs were associated with 608,686 hospitalizations over the 9 years.

Table 1 presents the characteristics of the PCPs who contributed to the cross‐sectional analyses in 2001 (N=2252) and 2009 (N=2387), as well as the 1172 PCPs for whom we had data for all 9 years for the longitudinal analyses. Most PCPs were male, trained in the United States, and were board certified. The average number of Medicare patients seen by these PCPs and number of outpatient Medicare visits went up about 7% between 2001 and 2009.

Figure 1 graphs the percentage of PCPs as a function of what percent of their hospitalized patients received care from hospitalists, and how that changed from 2001 to 2009. For 70.9% of PCPs, fewer than 5% of their hospitalized patients received hospitalist care in 2001. By 2009, the percent of PCPs in this category had decreased to 15.2%. In contrast, in 2001, more than half of the patients for 2.1% of PCPs received hospitalist care, and the percent of PCPs in this category increased to 26.3% by 2009.

Figure 1

The pattern in Figure 1 shows that PCPs' use of hospitalists changed continuously and gradually over time. However, this pattern describes the PCPs as a group. When examined at the individual PCP level, different patterns emerge. Figure 2, which presents selected individual PCP's use of hospitalists over time, shows several distinct subpatterns of PCP practice behaviors. First, there are PCPs whose use of hospitalists was high in 2001 and stayed high or increased over time (eg, PCP A). There also were PCPs whose use of hospitalists stayed low over the entire study period (eg, PCP B). Finally, there were PCPs whose use of hospitalists was low in 2001 but high in 2009 (eg, PCP C). For this last group, the pattern of change in hospitalist utilization over time was discontinuous; that is, most of the increase occurred over a 1‐ or 2‐year period, instead of increasing gradually over time.

Figure 2

Among the 1172 PCPs associated with 20 hospitalized beneficiaries each year in all 9 years of the study period, group‐based trajectory modeling classified their practice patterns into 4 distinct trajectories (Figure 3). Among PCPs in group 1, more than one‐third of their hospitalized patients were cared for by hospitalists in 2001, and this increased to 60% by 2009. PCPs in groups 2 and 3 rarely used hospitalist care in 2001 but increased their use over time. The increase started early in the period for PCPs in group 2 and later for those in group 3. PCPs in group 4 were associated with little hospitalist use throughout the study period.

Figure 3

We constructed a model to describe the odds of a patient receiving care from hospitalists during the study period using patients associated with these 1172 PCPs. After adjusting for patient characteristics, the residual intraclass correlation coefficient for PCP level was 0.334, which indicates that 33.4% of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. When adjusting for both patient and PCP characteristics, the overall odds of a patient receiving hospitalist care increased by 30% (95% confidence interval [CI]: 1.29‐1.30) per year from 2001 through 2009.

There were also significant interactions between year of hospitalization and several PCP characteristics. These interactions are illustrated in Table 2, which stratifies each of those PCP characteristics by 3 time periods: 2001 to 2003, 2004 to 2006, and 2007 to 2009. In all time periods, patients were more likely to receive hospitalist care if their PCP was US trained (US vs international medical graduate: odds ratio [OR]: 1.42, 95% CI: 1.19‐1.69 in 20012003; OR: 1.46, 95% CI: 1.23‐1.73 in 20072009), or specialized in family medicine (family medicine vs internal medicine: OR: 1.46, 95% CI: 1.25‐1.72 in 20012003; OR: 1.46, 95% CI: 1.25‐1.70 in 20072009). Over time, the relative odds of a patient receiving care from hospitalists decreased if their PCP was female (female vs male: OR: 1.91, 95% CI: 1.46‐2.50 in 20012003 vs OR: 1.50, 95% CI: 1.15‐1.95 in 20072009) or practiced in an urban area (largest vs smallest MSA: OR: 3.34, 95% CI: 2.72‐4.09 in 20012003; OR: 2.22, 95% CI: 1.82‐2.71 in 20072009). Although the longest‐practicing PCPs were most likely to use hospitalists in the early 2000s, this effect disappeared by 2007 to 2009 (most vs least years in practice: OR: 1.35, 95% CI: 1.06‐1.72 in 20012003 vs OR: 0.92, 95% CI: 0.73‐1.17 in 20072009).

In terms of PCP workload, patients of PCPs with high outpatient activity were more likely to receive hospitalists care throughout the study period, although the association had decreased by 2007 to 2009 (highest vs lowest outpatient volume: OR: 1.46, 95% CI: 1.30‐1.63 in 20012003 vs OR: 1.32, 95% CI: 1.20‐1.44 in 20072009). In contrast, PCPs with the lowest inpatient volumes became more likely to use hospitalists by the end of the study period (highest vs lowest inpatient volume: OR: 1.05, 95% CI: 0.95‐1.18 in 20012003 vs OR: 0.55, 95% CI: 0.51‐0.60 in 20072009).

The characteristics of PCPs' practice panels also were associated with patients' likelihood of receiving care from hospitalists. PCPs whose practice panels consisted of patients who were predominantly male, white, or with more outpatient comorbidities were consistently more likely to use hospitalists throughout the study period. PCPs with older patient panels were less likely to use hospitalists in 2001 to 2003, but by 2007 to 2009, they were slightly more likely to do so (oldest vs youngest average outpatient panel age: OR: 0.72, 95% CI: 0.64‐0.81 in 20012003 vs OR: 1.15, 95% CI: 1.05‐1.26 in 20072009).

CONCLUSIONS

Prior studies of the hospitalist model have shown that the likelihood of a patient receiving inpatient care from hospitalists is associated with patient characteristics, hospital characteristics, geographic region, and type of admission.[1, 16, 17] We found that PCP characteristics also predict whether patients receive care from hospitalists and that their use of hospitalists developed dynamically between 2001 to 2009. Although many factors (such as whether patients were admitted to a hospital where their PCP had admitting privileges) can influence the decision to use hospitalists, we found that over one‐third of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. In showing that systemic differences exist among PCPs who use hospitalists and those who do not, our study suggests that future research on the hospitalist model should, if possible, adjust for PCP characteristics in addition to hospital and patient factors.

Although this study identifies the existence and magnitude of differences in whether or not PCPs use hospitalists, it cannot explain why the differences exist. We only can offer hypotheses. For example, our finding that PCPs with the most years of practice experience were more likely to use hospitalists in the early 2000s but not in more recent years suggests that in hospital medicine's early years, long‐practicing generalist physicians were choosing between practicing traditionalist medicine and adopting the hospitalists model, but by 2009, experienced generalist physicians had already specialized to either inpatient or outpatient settings earlier in their careers. On the other hand, the decreasing odds of urban PCPs using hospitalists may reflect a relative growth in hospitalist use in less populated areas rather than a change in urban PCPs' practice patterns.

PCPs trained in family medicine have reported less inpatient training and less comfort with providing hospital care,[18, 19] thus it is unsurprising that family physicians were more likely to refer patients to hospitalists. Although a recent study reported that family physicians' inpatient volumes remained constant, whereas those of outpatient internists declined between 2003 and 2012, the analysis used University Health Consortium data and thus reflects practice patterns in academic medical centers.[20] Our data suggest that outside of academia, family physicians have embraced the hospitalists as clinical partners.

Meltzer and Chung had previously proposed an economic model to describe the growing use of hospitalists in the United States. They posited that decisions to adopt the hospitalist model are governed by trade‐offs between coordination costs (eg, time and effort spent coordinating multiple providers across different settings) and switching costs (eg, time spent traveling between the office and the hospital or the effort of adjusting to different work settings).[16] The authors hypothesized that empirical testing of this model would show PCPs are more likely to use hospitalists if they have less available professional time (ie, work fewer hours per week), are female (due to competing demands from domestic responsibilities), have relatively few hospitalized patients, or live in areas with high traffic congestion. Our findings provide empirical evidence to support their division‐of‐labor model in showing that patients were more likely to receive hospitalist care if their PCP was female, practiced in an urban location, had higher outpatient practice volumes, or had lower inpatient volumes.

At first glance, some of our findings appear to contradict our earlier study, which showed that younger, black, male patients are more likely to receive inpatient care from hospitalists.[1] However, that study included patients regardless of whether they had a PCP. This study shows that when patients have a PCP, their PCPs are more likely to refer them to hospitalists if they are older, white, male, and have more comorbid conditions. A potential explanation for this finding is that PCPs may preferentially use hospitalists when caring for older and sicker hospitalized patients. For example, commentators often cite hospitalists' constant availability in the hospital as a valuable resource when caring for acutely ill patients.[21, 22]

Another potential explanation is that despite their preferences, PCPs who care for younger, minority patients lack access to hospitalist services. One large study of Medicare beneficiaries reported that physicians who care for black patients are less well‐trained clinically and often lack access to important clinical resources such as diagnostic imaging and nonemergency hospital admissions.[23] Similarly, international medical graduates are more likely than their US‐trained counterparts to care for underserved patients and to practice in small, independent offices.[24, 25, 26] As hospitalist groups often rely on cross‐subsidization from sources within a large healthcare organization, independent PCPs may have less access to their services when compared with PCPs in managed care organizations or large integrated groups. Viewed in this context, our findings imply that although hospitalists often care for socioeconomically vulnerable patients (eg, younger, uninsured, black men) who lack access to primary care services,[1] they also appear to share care responsibilities for more complex hospitalized patients with PCPs in more affluent communities. Further research may determine if the availability of hospitalists influences racial disparities in hospital care.

Our study has limitations. It is an observational study and thus subject to bias and confounding. As our cohort was formed using fee‐for‐service Medicare data in a single, large state, it may not be generalizable to PCPs who practice in other states, who care for a younger population, or who do not accept Medicare. Our findings also may not reflect the practice patterns of physicians‐in‐training, PCP populations with high board‐certification rates, those employed in temporary positions, or those who interrupt their practices for personal reasons, as we restricted our study to established PCPs who had been in practice long and consistently enough to be associated with 20 hospitalized patients during every year of the study. For example, the lower proportion of female PCPs in our cohort (15.6% in our study in 2009 vs 27.5% reported in a nationally representative 2008 survey[27]) may be explained by our exclusion of women who take prolonged time off for childcare duties. We also did not establish whether patient outcomes or healthcare costs differ between PCPs who adopted the hospitalist model and traditionalists. Finally, we could not examine the effect of a number of PCP factors that could plausibly influence whether or not PCPs relinquish inpatient care to hospitalists, such as their comfort with providing inpatient care, having hospital admitting privileges, having office‐based access to hospitals' electronic medical records, or the distance between their office and the hospital. However, this study lays the groundwork for future studies to explore these factors.

In summary, this study is the first, to our knowledge, to characterize PCPs who relinquished inpatient responsibilities to hospitalists. Our findings suggest that some groups of PCPs are more likely to refer patient to hospitalists, that the relationship between hospitalists and PCPs has evolved over time, and that the hospitalist model still has ample room to grow.

Although primary care physicians (PCPs) have traditionally treated patients in both ambulatory and hospital settings, many relinquished inpatient duties to hospitalists in recent decades.[1] Little is known about the PCPs who relinquished inpatient care duties or how the transition to the hospitalist model occurred. For example, what are the characteristics of PCPs who change? Do PCPs adopt the hospitalist model enthusiastically or cautiously? Characterizing PCPs who adopted the hospitalist model can help hospitalists understand their specialty's history and also inform health services research.

Much of the interest in the hospitalist model has been generated by studies reporting improved outcomes and lower hospital lengths of stay associated with hospitalist care.[2, 3, 4, 5] Conversely, detractors of the model point to reports of higher postacute care utilization among hospitalist patients.[6] Although these studies usually adjusted for differences among patients and hospitals, they did not account for PCP characteristics. As patients' access to PCPs and their PCP's capabilities are both plausible factors that could influence hospital length of stay (eg, decisions to complete more or less of a workup in the hospital), quality of care transitions, and postdischarge utilization, it is important to determine if PCPs who use hospitalists differ systematically from those who do not to correctly interpret health system utilization patterns that currently are attributed only to hospitalists.[7, 8]

We conducted this study to determine if observable PCP factors are associated with patients' use of hospitalists and to describe the trajectory by which PCPs referred their patients to hospitalists over time.

METHODS

RESULTS

During the 2001 through 2009 study period, between 2252 and 2848 PCPs were associated with at least 20 hospitalized beneficiaries in any single year. Among these, 1172 PCPs were associated with at least 20 hospitalized beneficiaries in every year of the study period. These 1172 PCPs were associated with 608,686 hospitalizations over the 9 years.

Table 1 presents the characteristics of the PCPs who contributed to the cross‐sectional analyses in 2001 (N=2252) and 2009 (N=2387), as well as the 1172 PCPs for whom we had data for all 9 years for the longitudinal analyses. Most PCPs were male, trained in the United States, and were board certified. The average number of Medicare patients seen by these PCPs and number of outpatient Medicare visits went up about 7% between 2001 and 2009.

Figure 1 graphs the percentage of PCPs as a function of what percent of their hospitalized patients received care from hospitalists, and how that changed from 2001 to 2009. For 70.9% of PCPs, fewer than 5% of their hospitalized patients received hospitalist care in 2001. By 2009, the percent of PCPs in this category had decreased to 15.2%. In contrast, in 2001, more than half of the patients for 2.1% of PCPs received hospitalist care, and the percent of PCPs in this category increased to 26.3% by 2009.

Figure 1

The pattern in Figure 1 shows that PCPs' use of hospitalists changed continuously and gradually over time. However, this pattern describes the PCPs as a group. When examined at the individual PCP level, different patterns emerge. Figure 2, which presents selected individual PCP's use of hospitalists over time, shows several distinct subpatterns of PCP practice behaviors. First, there are PCPs whose use of hospitalists was high in 2001 and stayed high or increased over time (eg, PCP A). There also were PCPs whose use of hospitalists stayed low over the entire study period (eg, PCP B). Finally, there were PCPs whose use of hospitalists was low in 2001 but high in 2009 (eg, PCP C). For this last group, the pattern of change in hospitalist utilization over time was discontinuous; that is, most of the increase occurred over a 1‐ or 2‐year period, instead of increasing gradually over time.

Figure 2

Among the 1172 PCPs associated with 20 hospitalized beneficiaries each year in all 9 years of the study period, group‐based trajectory modeling classified their practice patterns into 4 distinct trajectories (Figure 3). Among PCPs in group 1, more than one‐third of their hospitalized patients were cared for by hospitalists in 2001, and this increased to 60% by 2009. PCPs in groups 2 and 3 rarely used hospitalist care in 2001 but increased their use over time. The increase started early in the period for PCPs in group 2 and later for those in group 3. PCPs in group 4 were associated with little hospitalist use throughout the study period.

Figure 3

We constructed a model to describe the odds of a patient receiving care from hospitalists during the study period using patients associated with these 1172 PCPs. After adjusting for patient characteristics, the residual intraclass correlation coefficient for PCP level was 0.334, which indicates that 33.4% of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. When adjusting for both patient and PCP characteristics, the overall odds of a patient receiving hospitalist care increased by 30% (95% confidence interval [CI]: 1.29‐1.30) per year from 2001 through 2009.

There were also significant interactions between year of hospitalization and several PCP characteristics. These interactions are illustrated in Table 2, which stratifies each of those PCP characteristics by 3 time periods: 2001 to 2003, 2004 to 2006, and 2007 to 2009. In all time periods, patients were more likely to receive hospitalist care if their PCP was US trained (US vs international medical graduate: odds ratio [OR]: 1.42, 95% CI: 1.19‐1.69 in 20012003; OR: 1.46, 95% CI: 1.23‐1.73 in 20072009), or specialized in family medicine (family medicine vs internal medicine: OR: 1.46, 95% CI: 1.25‐1.72 in 20012003; OR: 1.46, 95% CI: 1.25‐1.70 in 20072009). Over time, the relative odds of a patient receiving care from hospitalists decreased if their PCP was female (female vs male: OR: 1.91, 95% CI: 1.46‐2.50 in 20012003 vs OR: 1.50, 95% CI: 1.15‐1.95 in 20072009) or practiced in an urban area (largest vs smallest MSA: OR: 3.34, 95% CI: 2.72‐4.09 in 20012003; OR: 2.22, 95% CI: 1.82‐2.71 in 20072009). Although the longest‐practicing PCPs were most likely to use hospitalists in the early 2000s, this effect disappeared by 2007 to 2009 (most vs least years in practice: OR: 1.35, 95% CI: 1.06‐1.72 in 20012003 vs OR: 0.92, 95% CI: 0.73‐1.17 in 20072009).

In terms of PCP workload, patients of PCPs with high outpatient activity were more likely to receive hospitalists care throughout the study period, although the association had decreased by 2007 to 2009 (highest vs lowest outpatient volume: OR: 1.46, 95% CI: 1.30‐1.63 in 20012003 vs OR: 1.32, 95% CI: 1.20‐1.44 in 20072009). In contrast, PCPs with the lowest inpatient volumes became more likely to use hospitalists by the end of the study period (highest vs lowest inpatient volume: OR: 1.05, 95% CI: 0.95‐1.18 in 20012003 vs OR: 0.55, 95% CI: 0.51‐0.60 in 20072009).

The characteristics of PCPs' practice panels also were associated with patients' likelihood of receiving care from hospitalists. PCPs whose practice panels consisted of patients who were predominantly male, white, or with more outpatient comorbidities were consistently more likely to use hospitalists throughout the study period. PCPs with older patient panels were less likely to use hospitalists in 2001 to 2003, but by 2007 to 2009, they were slightly more likely to do so (oldest vs youngest average outpatient panel age: OR: 0.72, 95% CI: 0.64‐0.81 in 20012003 vs OR: 1.15, 95% CI: 1.05‐1.26 in 20072009).

CONCLUSIONS

Prior studies of the hospitalist model have shown that the likelihood of a patient receiving inpatient care from hospitalists is associated with patient characteristics, hospital characteristics, geographic region, and type of admission.[1, 16, 17] We found that PCP characteristics also predict whether patients receive care from hospitalists and that their use of hospitalists developed dynamically between 2001 to 2009. Although many factors (such as whether patients were admitted to a hospital where their PCP had admitting privileges) can influence the decision to use hospitalists, we found that over one‐third of the variance in whether a hospitalized patient received care from a hospitalist is explained by which PCP the patient saw. In showing that systemic differences exist among PCPs who use hospitalists and those who do not, our study suggests that future research on the hospitalist model should, if possible, adjust for PCP characteristics in addition to hospital and patient factors.

Although this study identifies the existence and magnitude of differences in whether or not PCPs use hospitalists, it cannot explain why the differences exist. We only can offer hypotheses. For example, our finding that PCPs with the most years of practice experience were more likely to use hospitalists in the early 2000s but not in more recent years suggests that in hospital medicine's early years, long‐practicing generalist physicians were choosing between practicing traditionalist medicine and adopting the hospitalists model, but by 2009, experienced generalist physicians had already specialized to either inpatient or outpatient settings earlier in their careers. On the other hand, the decreasing odds of urban PCPs using hospitalists may reflect a relative growth in hospitalist use in less populated areas rather than a change in urban PCPs' practice patterns.

PCPs trained in family medicine have reported less inpatient training and less comfort with providing hospital care,[18, 19] thus it is unsurprising that family physicians were more likely to refer patients to hospitalists. Although a recent study reported that family physicians' inpatient volumes remained constant, whereas those of outpatient internists declined between 2003 and 2012, the analysis used University Health Consortium data and thus reflects practice patterns in academic medical centers.[20] Our data suggest that outside of academia, family physicians have embraced the hospitalists as clinical partners.

Meltzer and Chung had previously proposed an economic model to describe the growing use of hospitalists in the United States. They posited that decisions to adopt the hospitalist model are governed by trade‐offs between coordination costs (eg, time and effort spent coordinating multiple providers across different settings) and switching costs (eg, time spent traveling between the office and the hospital or the effort of adjusting to different work settings).[16] The authors hypothesized that empirical testing of this model would show PCPs are more likely to use hospitalists if they have less available professional time (ie, work fewer hours per week), are female (due to competing demands from domestic responsibilities), have relatively few hospitalized patients, or live in areas with high traffic congestion. Our findings provide empirical evidence to support their division‐of‐labor model in showing that patients were more likely to receive hospitalist care if their PCP was female, practiced in an urban location, had higher outpatient practice volumes, or had lower inpatient volumes.

At first glance, some of our findings appear to contradict our earlier study, which showed that younger, black, male patients are more likely to receive inpatient care from hospitalists.[1] However, that study included patients regardless of whether they had a PCP. This study shows that when patients have a PCP, their PCPs are more likely to refer them to hospitalists if they are older, white, male, and have more comorbid conditions. A potential explanation for this finding is that PCPs may preferentially use hospitalists when caring for older and sicker hospitalized patients. For example, commentators often cite hospitalists' constant availability in the hospital as a valuable resource when caring for acutely ill patients.[21, 22]

Another potential explanation is that despite their preferences, PCPs who care for younger, minority patients lack access to hospitalist services. One large study of Medicare beneficiaries reported that physicians who care for black patients are less well‐trained clinically and often lack access to important clinical resources such as diagnostic imaging and nonemergency hospital admissions.[23] Similarly, international medical graduates are more likely than their US‐trained counterparts to care for underserved patients and to practice in small, independent offices.[24, 25, 26] As hospitalist groups often rely on cross‐subsidization from sources within a large healthcare organization, independent PCPs may have less access to their services when compared with PCPs in managed care organizations or large integrated groups. Viewed in this context, our findings imply that although hospitalists often care for socioeconomically vulnerable patients (eg, younger, uninsured, black men) who lack access to primary care services,[1] they also appear to share care responsibilities for more complex hospitalized patients with PCPs in more affluent communities. Further research may determine if the availability of hospitalists influences racial disparities in hospital care.

Our study has limitations. It is an observational study and thus subject to bias and confounding. As our cohort was formed using fee‐for‐service Medicare data in a single, large state, it may not be generalizable to PCPs who practice in other states, who care for a younger population, or who do not accept Medicare. Our findings also may not reflect the practice patterns of physicians‐in‐training, PCP populations with high board‐certification rates, those employed in temporary positions, or those who interrupt their practices for personal reasons, as we restricted our study to established PCPs who had been in practice long and consistently enough to be associated with 20 hospitalized patients during every year of the study. For example, the lower proportion of female PCPs in our cohort (15.6% in our study in 2009 vs 27.5% reported in a nationally representative 2008 survey[27]) may be explained by our exclusion of women who take prolonged time off for childcare duties. We also did not establish whether patient outcomes or healthcare costs differ between PCPs who adopted the hospitalist model and traditionalists. Finally, we could not examine the effect of a number of PCP factors that could plausibly influence whether or not PCPs relinquish inpatient care to hospitalists, such as their comfort with providing inpatient care, having hospital admitting privileges, having office‐based access to hospitals' electronic medical records, or the distance between their office and the hospital. However, this study lays the groundwork for future studies to explore these factors.

In summary, this study is the first, to our knowledge, to characterize PCPs who relinquished inpatient responsibilities to hospitalists. Our findings suggest that some groups of PCPs are more likely to refer patient to hospitalists, that the relationship between hospitalists and PCPs has evolved over time, and that the hospitalist model still has ample room to grow.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.

The growth of academic hospital medicine has been driven by multiple factors including expanding clinical needs, housestaff duty hours' limitations, and an increasing focus on quality and patient safety.1 Hospitalists at academic medical centers frequently assume roles that differ substantially from traditional faculty positions. Academic hospitalists may have predominantly clinical positions, and may be involved in quality improvement and patient safety projects.24 Because of these commitments, many academic hospitalists spend less time on research or educational efforts.1, 5 Many have raised concerns that these unique job descriptions might lead to less time to devote to scholarship and academic pursuits, and consequently greater challenges in the promotions process.2, 5

There are little published data on promotion and tenure in academics, and even less specifically focused on the promotion of hospitalists. Theoretically, promotion should recognize an individual's contribution to his or her institution and field. However, each institution has unique criteria though which faculty achieve promotion. Previous articles addressing specific groups, such as part‐time,6 clinical faculty,79 or clinician‐educators10 may be relevant to hospitalists, as hospitalists may be more likely to fall into these categories. These reports suggest general agreement that promotion committees should consider and weigh clinical and educational work (in addition to scholarly publications) in the promotions process, but assessment methods vary across institutions and the contribution of activities, such as quality improvement, remain unclear. The educator's portfolio has gained momentum as a way to document valued teaching in many institutions,11, 12 but academic hospitalist participation in education may be limited.13

Literature related to the development of Divisions of General Internal Medicine is relevant insofar as similar concerns for promotion were expressed with the growth of their faculty.14, 15 However, its applicability may be limited by differences between roles of hospitalists and more traditional general medicine faculty.

To better understand the factors influencing promotion for academic hospitalists, the Society of General Internal Medicine (SGIM) Academic Hospitalist Task Force (AHTF) undertook a survey of promoted hospitalists who had successfully reached the rank of Associate Professor or higher.

Methods

Results

Of the 33 hospitalists who received the survey, 26 responded (response rate of 79%). Of these, 25 completed the survey in its entirely and were included in our analysis; 1 did not submit details regarding specific promotion‐related activities. General information regarding the respondents and their programs at the time of their promotion is contained in Table 1.

The seven nonrespondents were from seven different institutions; however two of these institutions were represented by respondents. One nonrespondent had achieved a rank of Professor (through general medicine); the rest had been promoted to Associate Professor. One nonrespondent is known by the authors to hold a research position.

Ten respondents identified themselves as clinician‐educators (40%), ten as clinician‐administrators (40%), and five as clinician‐researchers (20%). Seventeen (68%) of the promoted hospitalists were not on a tenure track (as defined by them); they were more likely to have administrative or educational roles than a research appointment. Though the majority of self‐identified researchers were among the earliest to have been promoted, there were no statistically significant differences in self‐defined job description between more and less recently promoted hospitalists.

Promoted hospitalists were involved in a diverse range of activities which supported their promotion, including service (eg, institutional committees), education, research, and quality improvement. Nearly all hospitalists surveyed listed teaching and educational activities, and almost all had disseminated scholarly output and some degree of grant funding. Table 2 lists the specific activities in which respondents reported being engaged in each of these domains.

A range of individuals assisted the respondents in the promotion process. Twenty‐three (92%) respondents identified the individuals who supported their promotion, and all listed more than one person. Respondents most commonly credited their Section or Division Chief (43%) with facilitating their promotion, followed by Departmental Chairs or Vice/Associate Chairs (22%). Mentors (13%) or peers (8%) were also named. Four respondents (17%) named themselves as the person providing most guidance through the promotions process.

No consistent themes regarding obstacles emerged from free‐text responses to questions about the promotions process. One respondent felt that high clinical expectations made participation in other academic activities a challenge. The only other barriers noted were not being on the radar screen of the Division Chief of GIM, and difficulty identifying external, senior hospitalists to write letters in support of promotion.

When asked about the most important activities supporting their promotion, 24 respondents listed one to two key activities, detailed in Table 3. The most common response was peer‐reviewed publications (33%). Activities related to education and/or teaching were the next most common response (29%), specifically teaching, educational activities, curriculum design, or program director. Research or research funding represented 26% of responses. Valued activities outside of the respondent's institution included national reputation (21%) and service in professional societies (16%). Service or administrative responsibilities were mentioned by 25% of respondents.

Discussion

We conducted a unique and comprehensive survey of academic hospitalists who have been promoted since 1995. We identified the most common and important activities contributing to promotion. Contrary to our expectations, survey respondents generally did not report being a hospitalist was a barrier in the promotions process.

Respondents were engaged in a diverse range of activities, including service, education, and research. Interestingly, no one identified him or herself primarily as a clinician. Teaching appeared to be a core component for all surveyed, regardless of academic appointment. Only one felt that her clinical workload as a hospitalist was an obstacle that prevented her from being engaged in other activities important for promotion. With more programs potentially evolving to separate divisions, the issue of being on the radar screen of a General Internal Medicine Division Chief may become less common over time. We hope that as programs mature and the numbers of associate and full professors increase, there will not be difficulty obtaining outside letters.

Although only 23% self‐identified as clinician‐researchers, nearly all had peer‐reviewed publications and other evidence of disseminated scholarly work. Grant funding, both federal and nonfederal, was also common among this group. This finding is consistent with self‐reported activities of a cohort of junior internal medicine faculty followed over three years who were eventually promoted, though the majority of those participants were classified as having either traditional clinician‐educator or clinician‐researcher positions.16

Despite outlining a seemingly clear pathway to promotion for hospitalists, concerns remain. Most importantly, those surveyed seem to have achieved promotion through relatively traditional academic job descriptions. Obtaining or maintaining these types of positions may be difficult as clinical needs at academic centers increase. According to a recent survey of hospitalist faculty,13 over one‐third spend more than 60% of their time on nonteaching clinical services. In that survey, over half of respondents had little or no protected time for scholarly activities. The contrast between this survey's findings and ours raises the question of whether our promoted sample had positions similar to those of most academic hospitalists. Given that the majority of our respondents noted peer‐reviewed publications and grant funding to be among the most important activities for promotion, there may be a dangerous disconnect for junior academic hospitalists who spend the majority of their time in direct patient care. Moreover, the promoted hospitalists in our survey reported relatively less participation in quality improvement/patient safety activities, in contrast to both anecdotal and survey reports that these activities are a major component of many academic hospitalist positions.5, 17 Most academic medical centers do not yet consider achievements in this area in their promotions criteria, potentially creating a barrier for the ranks of clinician quality improvers.1 Thus, significant obstacles to promotion of academic hospitalists may exist.

Leaders in academic hospital medicine are recognizing these potential barriers. A diverse group from major professional societies recently published a summary of the challenges and opportunities for the field of academic hospital medicine.1 Several needs and areas for intervention were identified, including enhanced faculty development and improved documentation of quality improvement activities. The SGIM, the SHM, and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM) recently cosponsored an intensive four‐day faculty development course for junior faculty to promote skills necessary for academic hospitalist success. Early reports indicate that this was a success.1820

In addition, the AHTF has developed a Quality Portfolio, paralleling the Educator's Portfolio, that can be used as a tool for documenting quality improvement and patient safety activities in a way that can be useful for career development and promotion.4 Lastly, the Society of Hospital Medicine has hosted the inaugural Academic Hospital Medicine Leadership Summit as part of the national meeting to provide mentorship and professional development opportunities for junior faculty. Our hope is that these opportunities, coupled with the growth of mid‐level and senior leaders in hospital medicine, will provide greater infrastructure for the development and promotion of junior faculty.

Our results may have relevance beyond hospitalist groups. With anticipated further limits on housestaff duty hours, more academic physicians may be asked to fill predominantly clinical roles. In addition, a growing emphasis on quality and patient safety may lead to a more general expansion of academicians who focus on these areas.15

Our survey and methodology have limitations. By including only promoted individuals, we did not survey hospitalists with the most difficulties in the promotions processthose who were not promoted. Thus, we are unable to directly compare successful versus unsuccessful strategies. Identifying nonpromoted academic hospitalists to understand the reasons they were not (or have not yet been) promoted could be a next step in this line of inquiry. Additionally, understanding the attitudes of promotions committees regarding hospitalists, and the clinical and quality improvement roles in which they are engaged, could enhance our current results. Finally, we surveyed a convenience sample of a limited numbers of hospitalists and institutions, and were unable to systematically account for variations in promotions criteria across institutions. However, to our knowledge, this is the most comprehensive study of promotions among academic hospitalists to date. Given the common themes that emerged in terms of activities that supported promotion, mentors, and advice, we believe that our sample was sufficient to identify important themes and advance our understanding of this nascent specialty.

In conclusion, our survey of promoted hospital medicine faculty provides valuable information for junior faculty and hospitalist leaders. Success was found through engaging in a diverse set of activities in the traditional areas of education, service, and scholarship, frequently in conjunction with developing recognition outside of their institutions. While all respondents were clinically active, none described themselves as having purely clinical roles. As academic hospitalist roles evolve, academic leaders will need to provide adequate mentorship, create time for scholarly pursuits, and promote documentation and recognition of nontraditional activities that may nonetheless be worthy of promotion.