Flora Kisuule, MD, MPH

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

Promotion through the ranks is the hallmark of success in academia. The support and infrastructure necessary to develop junior faculty members at academic medical centers may be inadequate.1, 2 Academic hospitalists are particularly vulnerable and at high risk for failure because of their heavy clinical commitment and limited time to pursue scholarly interests. Further, relatively few have pursued fellowship training, which means that many hospitalists must learn research‐related skills and the nuances of academia after joining the faculty.

Top‐notch mentors are believed to be integral to the success of the academic physician.36 Among other responsibilities, mentors (1) direct mentees toward promising opportunities, (2) serve as advocates for mentees, and (3) lend expertise to mentees' studies and scholarship. In general, there is concern that the cadre of talented, committed, and capable mentors is dwindling such that they are insufficient in number to satisfy and support the needs of the faculty.7, 8 In hospital medicine, experienced mentorship is particularly in short supply because the field is relatively new and there has been tremendous growth in the number of academic hospitalists, producing a large demand.

Like many hospitalist groups, our hospitalist division, the Collaborative Inpatient Medicine Service (CIMS), has experienced significant growth. It became apparent that the faculty needed and deserved a well‐designed academic support program to foster the development of skills necessary for academic success. The remainder of this article discusses our approach toward fulfilling these needs and the results to date.

DEVELOPING THE HOSPITALIST ACADEMIC SUPPORT PROGRAM

EVALUATION DATA

In the 2 years since implementation of the scholarly support program, individual faculty in the CIMS have been meeting the above‐mentioned goals. Specifically, with respect to acquiring knowledge and skills, 2 faculty members have completed their master's degrees, and 6 others have made use of select courses to augment their knowledge and skills. All faculty members (100%) have a scholarly project they are leading, and most have reached out to a colleague in the CIMS to assist them, such that nearly all are team members on at least 1 other scholarly project. Through informal mentoring sessions and a once‐yearly formal meeting related to academic promotion, all members (100%) of the faculty are aware of the expectations and requirements for promotion.

Table 1 shows the accomplishment of the 5 faculty members in the academic track who have been division members for 3 years or more. Among the 5 faculty in the academic track, publications and extramural funding are improving. In the 5 years before the initiative, CIMS faculty averaged approximately 0.5 publications per person per year; in the first 2 years of this initiative, that number has increased to 1.3 publications per person per year. The 1 physician who has not yet been published has completed projects and has several article in process. External funding (largely in the form of 3 extramural grants from private foundations) has increased dramatically from an average of 4% per FTE before the intervention to approximately 15% per FTE afterward. In addition, all faculty members have secured a source of additional funding to reduce their clinical efforts since the implementation of this program. One foundation funded project that involved all division members, whose goal was to develop mechanisms to improve the discharge process of elderly patients to their homes, won the award at the SGIM 2007 National Meeting for the best clinical innovation. As illustrated in Table 1, 1 of the founding CIMS members transferred out of the academic track in 2003 in alignment with this physician's personal and professional goals and preferences. Two faculty members have moved up an academic rank, and several others are poised to do so.

Thus, the divisional objectives (increasing number of publications, securing funding to increase the time devoted to scholarship, new leadership roles, and progression toward promotion) are being met as well.

CONCLUSIONS

Our rapidly growing hospitalist division recognized that several factors threatened the ability of the division and individuals to succeed academically. Divisional, departmental, and medical center leadership was committed to creating a supportive structure that would be available to all hospitalists as opposed to expecting each individual to unearth the necessary resources on their own. The innovative approach to foster individual, and therefore divisional, academic and scholarly success was designed around the following strategies: retention of an expert mentor (who is a not a hospitalist) and securing 20% of his time, investing in scholarship by protecting 30% nonclinical time for academic pursuits, and attempting to seek out fellowship‐trained hospitalists when hiring.

Although quality mentorship, protected time, and recruiting the best‐available talent to fill needs may not seem all that innovative, we believe the systematic approach to the problem and our steadfast application of the strategic plan is unique, innovative, and may present a model to be emulated by other divisions. Some may contend that it is impossible to protect 30% FTE of academic hospitalists indefinitely. Our group has made substantial investment in supporting the academic pursuits of our physicians, and we believe this is essential to maintaining their satisfaction and commitment to scholarship. This amount of protected time is offered to the entire physician faculty and continues even as our division has almost tripled in size. This initiative represents a carefully calculated investment that has influenced our ability to recruit and retain excellent people. Ongoing prospective study of this intervention over time will provide additional perspective on its value and shortcomings. Nonetheless, early data suggest that the plan is indeed working and that our group is satisfied with the return on investment to date.

Promotion through the ranks is the hallmark of success in academia. The support and infrastructure necessary to develop junior faculty members at academic medical centers may be inadequate.1, 2 Academic hospitalists are particularly vulnerable and at high risk for failure because of their heavy clinical commitment and limited time to pursue scholarly interests. Further, relatively few have pursued fellowship training, which means that many hospitalists must learn research‐related skills and the nuances of academia after joining the faculty.

Top‐notch mentors are believed to be integral to the success of the academic physician.36 Among other responsibilities, mentors (1) direct mentees toward promising opportunities, (2) serve as advocates for mentees, and (3) lend expertise to mentees' studies and scholarship. In general, there is concern that the cadre of talented, committed, and capable mentors is dwindling such that they are insufficient in number to satisfy and support the needs of the faculty.7, 8 In hospital medicine, experienced mentorship is particularly in short supply because the field is relatively new and there has been tremendous growth in the number of academic hospitalists, producing a large demand.

Like many hospitalist groups, our hospitalist division, the Collaborative Inpatient Medicine Service (CIMS), has experienced significant growth. It became apparent that the faculty needed and deserved a well‐designed academic support program to foster the development of skills necessary for academic success. The remainder of this article discusses our approach toward fulfilling these needs and the results to date.

DEVELOPING THE HOSPITALIST ACADEMIC SUPPORT PROGRAM

EVALUATION DATA

In the 2 years since implementation of the scholarly support program, individual faculty in the CIMS have been meeting the above‐mentioned goals. Specifically, with respect to acquiring knowledge and skills, 2 faculty members have completed their master's degrees, and 6 others have made use of select courses to augment their knowledge and skills. All faculty members (100%) have a scholarly project they are leading, and most have reached out to a colleague in the CIMS to assist them, such that nearly all are team members on at least 1 other scholarly project. Through informal mentoring sessions and a once‐yearly formal meeting related to academic promotion, all members (100%) of the faculty are aware of the expectations and requirements for promotion.

Table 1 shows the accomplishment of the 5 faculty members in the academic track who have been division members for 3 years or more. Among the 5 faculty in the academic track, publications and extramural funding are improving. In the 5 years before the initiative, CIMS faculty averaged approximately 0.5 publications per person per year; in the first 2 years of this initiative, that number has increased to 1.3 publications per person per year. The 1 physician who has not yet been published has completed projects and has several article in process. External funding (largely in the form of 3 extramural grants from private foundations) has increased dramatically from an average of 4% per FTE before the intervention to approximately 15% per FTE afterward. In addition, all faculty members have secured a source of additional funding to reduce their clinical efforts since the implementation of this program. One foundation funded project that involved all division members, whose goal was to develop mechanisms to improve the discharge process of elderly patients to their homes, won the award at the SGIM 2007 National Meeting for the best clinical innovation. As illustrated in Table 1, 1 of the founding CIMS members transferred out of the academic track in 2003 in alignment with this physician's personal and professional goals and preferences. Two faculty members have moved up an academic rank, and several others are poised to do so.

Thus, the divisional objectives (increasing number of publications, securing funding to increase the time devoted to scholarship, new leadership roles, and progression toward promotion) are being met as well.

CONCLUSIONS

Our rapidly growing hospitalist division recognized that several factors threatened the ability of the division and individuals to succeed academically. Divisional, departmental, and medical center leadership was committed to creating a supportive structure that would be available to all hospitalists as opposed to expecting each individual to unearth the necessary resources on their own. The innovative approach to foster individual, and therefore divisional, academic and scholarly success was designed around the following strategies: retention of an expert mentor (who is a not a hospitalist) and securing 20% of his time, investing in scholarship by protecting 30% nonclinical time for academic pursuits, and attempting to seek out fellowship‐trained hospitalists when hiring.

Although quality mentorship, protected time, and recruiting the best‐available talent to fill needs may not seem all that innovative, we believe the systematic approach to the problem and our steadfast application of the strategic plan is unique, innovative, and may present a model to be emulated by other divisions. Some may contend that it is impossible to protect 30% FTE of academic hospitalists indefinitely. Our group has made substantial investment in supporting the academic pursuits of our physicians, and we believe this is essential to maintaining their satisfaction and commitment to scholarship. This amount of protected time is offered to the entire physician faculty and continues even as our division has almost tripled in size. This initiative represents a carefully calculated investment that has influenced our ability to recruit and retain excellent people. Ongoing prospective study of this intervention over time will provide additional perspective on its value and shortcomings. Nonetheless, early data suggest that the plan is indeed working and that our group is satisfied with the return on investment to date.

Promotion through the ranks is the hallmark of success in academia. The support and infrastructure necessary to develop junior faculty members at academic medical centers may be inadequate.1, 2 Academic hospitalists are particularly vulnerable and at high risk for failure because of their heavy clinical commitment and limited time to pursue scholarly interests. Further, relatively few have pursued fellowship training, which means that many hospitalists must learn research‐related skills and the nuances of academia after joining the faculty.

Top‐notch mentors are believed to be integral to the success of the academic physician.36 Among other responsibilities, mentors (1) direct mentees toward promising opportunities, (2) serve as advocates for mentees, and (3) lend expertise to mentees' studies and scholarship. In general, there is concern that the cadre of talented, committed, and capable mentors is dwindling such that they are insufficient in number to satisfy and support the needs of the faculty.7, 8 In hospital medicine, experienced mentorship is particularly in short supply because the field is relatively new and there has been tremendous growth in the number of academic hospitalists, producing a large demand.

Like many hospitalist groups, our hospitalist division, the Collaborative Inpatient Medicine Service (CIMS), has experienced significant growth. It became apparent that the faculty needed and deserved a well‐designed academic support program to foster the development of skills necessary for academic success. The remainder of this article discusses our approach toward fulfilling these needs and the results to date.

DEVELOPING THE HOSPITALIST ACADEMIC SUPPORT PROGRAM

EVALUATION DATA

In the 2 years since implementation of the scholarly support program, individual faculty in the CIMS have been meeting the above‐mentioned goals. Specifically, with respect to acquiring knowledge and skills, 2 faculty members have completed their master's degrees, and 6 others have made use of select courses to augment their knowledge and skills. All faculty members (100%) have a scholarly project they are leading, and most have reached out to a colleague in the CIMS to assist them, such that nearly all are team members on at least 1 other scholarly project. Through informal mentoring sessions and a once‐yearly formal meeting related to academic promotion, all members (100%) of the faculty are aware of the expectations and requirements for promotion.

Table 1 shows the accomplishment of the 5 faculty members in the academic track who have been division members for 3 years or more. Among the 5 faculty in the academic track, publications and extramural funding are improving. In the 5 years before the initiative, CIMS faculty averaged approximately 0.5 publications per person per year; in the first 2 years of this initiative, that number has increased to 1.3 publications per person per year. The 1 physician who has not yet been published has completed projects and has several article in process. External funding (largely in the form of 3 extramural grants from private foundations) has increased dramatically from an average of 4% per FTE before the intervention to approximately 15% per FTE afterward. In addition, all faculty members have secured a source of additional funding to reduce their clinical efforts since the implementation of this program. One foundation funded project that involved all division members, whose goal was to develop mechanisms to improve the discharge process of elderly patients to their homes, won the award at the SGIM 2007 National Meeting for the best clinical innovation. As illustrated in Table 1, 1 of the founding CIMS members transferred out of the academic track in 2003 in alignment with this physician's personal and professional goals and preferences. Two faculty members have moved up an academic rank, and several others are poised to do so.

Thus, the divisional objectives (increasing number of publications, securing funding to increase the time devoted to scholarship, new leadership roles, and progression toward promotion) are being met as well.

CONCLUSIONS

Our rapidly growing hospitalist division recognized that several factors threatened the ability of the division and individuals to succeed academically. Divisional, departmental, and medical center leadership was committed to creating a supportive structure that would be available to all hospitalists as opposed to expecting each individual to unearth the necessary resources on their own. The innovative approach to foster individual, and therefore divisional, academic and scholarly success was designed around the following strategies: retention of an expert mentor (who is a not a hospitalist) and securing 20% of his time, investing in scholarship by protecting 30% nonclinical time for academic pursuits, and attempting to seek out fellowship‐trained hospitalists when hiring.

Although quality mentorship, protected time, and recruiting the best‐available talent to fill needs may not seem all that innovative, we believe the systematic approach to the problem and our steadfast application of the strategic plan is unique, innovative, and may present a model to be emulated by other divisions. Some may contend that it is impossible to protect 30% FTE of academic hospitalists indefinitely. Our group has made substantial investment in supporting the academic pursuits of our physicians, and we believe this is essential to maintaining their satisfaction and commitment to scholarship. This amount of protected time is offered to the entire physician faculty and continues even as our division has almost tripled in size. This initiative represents a carefully calculated investment that has influenced our ability to recruit and retain excellent people. Ongoing prospective study of this intervention over time will provide additional perspective on its value and shortcomings. Nonetheless, early data suggest that the plan is indeed working and that our group is satisfied with the return on investment to date.

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.