Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.

Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.

Hospitalists are hospital‐based physicians whose primary professional focus is patient care, education, research, and administrative activities related to hospital medicine.1 Initially, community‐based hospitals were far more likely to employ hospitalists than academic centers. However, today most academic centers employ hospitalist models and it is now a fully recognized entity in academic settings.2

While much has been written about the structure, business operations, and potential benefits of nonteaching (clinical) hospitalist programs,3, 4 there is little known about the current state of academic hospitalist programs or their challenges. For example, who are the leaders of academic hospitalist medicine groups? Given the youth of the field, are academic hospitalists receiving adequate mentorship and are they advancing academically? What are future directions and goals for academic hospitalist groups?

To better understand academic hospitalist programs, we surveyed division chiefs and academic hospitalist leaders to explore existing business models and operations, the status of mentorship, and key issues in growth and retention.

Methods

Results

Discussion

Our survey provides a unique snapshot of academic hospitalist groups, highlighting a perceived lack of support and respect for their programs, a need to increase education and scholarly activities, and a desire to better prepare faculty for academic promotion.

Academic hospitalist groups and leaders reflected what one would expect from a field that is just over a decade old. Program leaders were relatively new to their position, as were their division group members. As a result, it is not surprising that most of the academic hospitalist leaders identified mentorship as a major issue. We were encouraged to see that most programs were offering annual reviews. However, the majority of these annual reviews were performed by the group leaders, many of whom are relatively junior (40% Assistant Professors) and may not be experienced in mentoring and performing annual reviews. Importantly, the absence of a mentor (or a high‐quality, experienced one) among physicians, and specifically hospitalists, may result in fewer peer‐reviewed first author and non‐peer‐reviewed publications, and less experience leading a teaching session at a national meeting.6 Research suggests that effective mentoring may help faculty increase career satisfaction and productivity and reduce their risk for burn‐out.7 Hospitalist groups might benefit nationally from focusing specifically on finding adequate mentorship either within or outside their groups. In addition, national organizations such as the SHM and the SGIM could potentially help these groups and individual hospitalists in creating mentorship networks and a mentoring infrastructure.

Academic hospitalist leaders were concerned about the ability of their faculty to develop sustainable nonclinical activities and scholarship. Notably, more than 40% of surveyed leaders agreed or strongly agreed that their faculty were not developing sustainable nonclinical activities. For individual faculty, the inability to develop scholarly activities and engage in academic pursuits may create challenges in getting promoted by traditional academic pathways. Some have recognized this issue and tried to develop practical solutions.2 In addition, academic hospitalists often engage in nonclinical activities such as quality improvement or patient safety which do not fit in the traditional tripartite mission of academics (clinical care, education, and research). In this survey, more than 90% of groups were engaged in quality improvement projects and over half in peer review exercises (Table 1). As many of these scholarly activities require innovation, sophisticated data analysis, and can have far‐reaching and substantial impacts on healthcare, some have argued these should be considered as part of the promotion process.8 Notably, the SGIM Academic Hospitalist Taskforce has created the Quality Portfolio, a structured adjunct to promotions packets to organize and document work in quality improvement and patient safety.9

While there were few CI in the divisions surveyed, building CI programs was a major priority of programs. In programs reporting the presence of CI's, they report limited access to research support. This highlights the potential role and benefit of post residency training in designing and conducting clinical research whether in a traditional general internal medicine fellowship or in 1 of the many growing hospital medicine fellowships.10 There also appears to be a need for funding to support the research careers of junior hospitalists. While access to effective mentorship is integrally linked to achieving increased academic accomplishments, there is certainly an ample call for research in the areas of quality improvement, patient safety; systems‐based practice, hospital efficiency, transitions of care,11 perioperative medicine,12 and education.2, 13, 14 While providing lower costs per admission and lower lengths of stay, hospitalists seem well‐positioned to spearhead active research in cost‐effectiveness in the hospital.14 Additionally, a quality portfolio, documenting such quality improvement projects, has been suggested as an effective means to provide a record of this work for academic promotion.9

The diverse activities of today's hospitalists are transforming the traditional view of academic work and are critical to the growth of hospitals, patient care, and development of the field of hospital medicine itself. Until these areas are fully embraced as legitimate areas of academic productivity and scholarship, the academic advancement of hospitalists will be slow.

It is unclear from our survey if academic hospitalist programs are truly getting the support they need to succeed. On one hand, there was general agreement that the Departments of Medicine and Divisions of General and Hospital Medicine were invested in the development of the academic accomplishments. Yet, the majority of program directors believed that they are viewed by the Department or Division as a clinical rather than an academic program. Moreover, over half of program directors report that their hospital was not supportive and therefore have limited the expansion of their hospitalist groups' educational and research activities. Lastly, for a large majority of programs, unavailable funding also acted to limit growth and expansion of academic functions. In a mere 2 decades, Emergency Medicine has become one of the largest US specialties and yet research and funding in the field have been lagging and are limiting academic expansion. Junior faculty seeking research careers struggled to find support and mentorship within their emergency medicine divisions.15 Challenges faced by academic emergency medicine provide important historical perspective for the even more rapidly growing field of academic hospital medicine. Learning from the Academic Emergency Medicine experience, academic hospitalists should proactively identify scholarship and research opportunities unique to hospitalist and fitting the needs of academic institutions. Involvement in national medical organizations, such as SGIM‐SHM‐ACGIM Academic Hospitalist Academy, or the SGIM Academic Hospitalist Task Force, where skill and career development is the focus, will undoubtedly promote the success of academic hospitalist. Expanding valuable niches of expertise, such as quality control, perioperative medicine and care transitions, create an indispensible component of hospital care. Lastly mentoring programs for academic hospitalist within SHM and SGIM are also essential for networking and career development. There are several limitations to our study. Our response rate of 40% was relatively low, and our results may not be representative of all academic hospitalist division chiefs and their programs, may be overstating the perceived difficulties of the survey sample, or conversely missing a large portion too overwhelmed by current duties who lacked the time to complete the survey. Having said this, our survey methodology targeted sites where we could identify potentialnot confirmedhospitalist groups and hospitalist group leaders. For this reason, our response rate could be higher (if some of our contacts were in error). Our results are a cross‐sectional survey based on self report and are subject to recall bias. In addition, our study was carried out in 2007, and while issues such as mentorship may remain important, our results regarding financial arrangements may not be applicable to the current economic climate. Finally, while improving mentorship was identified as a principle objective for program leaders, we did not explore the existing quality of mentorship, nor perceived shortfalls. This should be the subject of future exploration.

The vast majority of academic hospital medicine programs continue to view inadequate support, expanding research, mentorship, and academic promotion as critical issues for the future. Thus, further understanding of these features, and interventions to allow for success, are of crucial importance in the continued development of academic hospitalists. Our study supports the need for mentoring and career development programs, targeting academic hospitalists and their leaders. In addition, attention should be paid to activities that support career fit, creating sustainable and viable job descriptions for academic hospitalists, and preventing burnout.16 At the same time we must expand the traditional view of scholarship and training and advocate for promotion criteria that value the unique contributions of hospitalists to become in line with the broad areas that hospitalists work.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

The research‐in‐progress (RIP) conference is commonplace in academia, but there are no studies that objectively characterize its value. Bringing faculty together away from revenue‐generating activities carries a significant cost. As such, measuring the success of such gatherings is necessary.

Mentors are an invaluable influence on the careers of junior faculty members, helping them to produce high‐quality research.13 Unfortunately, some divisions lack mentorship to support the academic needs of less experienced faculty.1 Peer mentorship may be a solution. RIP sessions represent an opportunity to intentionally formalize peer mentoring. Further, these sessions can facilitate collaborations as individuals become aware of colleagues' interests. The goal of this study was to assess the value of the research‐in‐progress conference initiated within the hospitalist division at our institution.

Methods

Results

The mean number of attendees at the RIP sessions was 9.6 persons. A total of 143 evaluations were completed. All 15 presenters (100%) completed their assessments. The research ideas presented spanned a breadth of topics in clinical research, quality improvement, policy, and professional development (Table 1).

Discussion

In this article, we report our experience with the RIP conference. The sessions were perceived to be intellectually stimulating and supportive, whereas the discussions proved helpful in advancing project ideas. Ample discussion time and good attendance were thought to be critical to the success.

To our knowledge, this is the first article gathering feedback from attendees and presenters at a RIP conference and to track academic outcomes. Several types of meetings have been established within faculty and trainee groups to support and encourage scholarly activities.11, 12 The benefits of peer collaboration and peer mentoring have been described in the literature.13, 14 For example, Edwards described the success of shortstop meetings among small groups of faculty members every 4‐6 weeks in which discussions of research projects and mutual feedback would occur.15 Santucci described peer‐mentored research development meetings, with increased research productivity.12

Mentoring is critically important for academic success in medicine.1619 When divisions have limited senior mentors available, peer mentoring has proven to be indispensable as a mechanism to support faculty members.2022 The RIP conference provided a forum for peer mentoring and provided a partial solution to the limited resource of experienced research mentors in the division. The RIP sessions appear to have helped to bring the majority of presented ideas to academic fruition. Perhaps even more important, the sessions were able to terminate studies judged to have low academic promise before the faculty had invested significant time.

Several limitations of our study should be considered. First, this study involved a research‐in‐progress conference coordinated for a group of hospitalist physicians at 1 institution, and the results may not be generalizable. Second, although attendance was good at each conference, some faculty members did not come to many sessions. It is possible that those not attending may have rated the sessions differently. Session evaluations were anonymous, and we do not know whether specific attendees rated all sessions highly, thereby resulting in some degree of clustering. Third, this study did not compare the effectiveness of the RIP conference with other peer‐mentorship models. Finally, our study was uncontrolled. Although it would not be possible to restrict specific faculty from presenting at or attending the RIP conference, we intend to more carefully collect attendance data to see whether there might be a dose‐response effect with respect to participation in this conference and academic success.

In conclusion, our RIP conference was perceived as valuable by our group and was associated with academic success. In our division, the RIP conference serves as a way to operationalize peer mentoring. Our findings may help other groups to refine either the focus or format of their RIP sessions and those wishing to initiate such a conference.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

Discharge summaries (DS) correlate with rates of rehospitalization1, 2 and adverse events after discharge.3 The Joint Commission on the Accreditation of Healthcare Organizations acknowledges their importance and mandates that certain elements be included.4 Thus far, however, DS are not standardized across institutions and there is no expectation that they be available at postdischarge visits. There have been numerous attempts to improve the quality of DS by using more structured formats or computer generated summaries with positive results in term of comprehensiveness, clarity, and practitioner satisfaction58 but with persistence of serious errors and omissions.9

Postgraduate training is often the first opportunity for physicians to learn information transfer management skills. Unfortunately, DS are created by house staff who have minimal training in this area¹¹ and feel like they have to learn by osmosis,12 resulting in poor quality DS and lack of availability at the point of care.1315

Previous research suggested that individualized feedback sessions for Internal Medicine residents improved the quality of certain aspects of their completed DS.10 We postulated that an audit and feedback educational intervention on DS for first year geriatric medicine fellows would also improve their quality. This technique involves chart or case review of clinical practice behaviors for a specific task followed by recommendation of new behaviors when applicable.16 Audit and feedback incorporates adult learning theory,1719 an essential part of continuous quality improvement that fits within the Accreditation Council for Graduate Medical Education (ACGME) competency of practice based learning and improvement,20 as an educational activity.

Methods

Intervention

Audit #1

All available DS for each fellow's first month of inpatient service were audited for completeness of the 21 item discharge summary template by 1 author (AD). The 21 items were focused on 4 distinct periods of the hospitalization: admission, hospital course, discharge planning, and postdischarge care (Figure 1).

Figure 1

Content under each of the 21 items was classified as complete, partially complete, or absent. An item was considered complete if most information was present and appropriate medical terms were used, partially complete if information was unclear, and absent if no information was present for that area of the DS. To ensure investigator reliability, a random sample of 25% of each fellow's DS was scored by 2 additional investigators (RK and HF) and all disagreements were reviewed and resolved by consensus.

Feedback

Between December 2006 and January 2007, one‐on‐one formative feedback sessions were scheduled. The sessions were approximately 30 minutes long, confidential, performed by 1 of the authors (AD) and followed a written format. During these sessions, each fellow received the results of their discharge summary audit, each partially complete or absent item was discussed, and the importance of DS was emphasized.

Audit #2

All available DS for each fellow's second month of inpatient service were audited for completeness, using the same 21 item assessment tool and the same scoring system.

Results

Five fellows participated, 4 of whom were women; 2 were in postgraduate year 4, 3 in year 5. A total of 158 DS were audited, 89 prefeedback and 79 postfeedback. Each fellow dictated an average of 17 DS during each inpatient month.

During Audit #1, the 21 item DS were complete among 71%, incomplete among 18%, absent among 11%. Admission items, hospital course items, and discharge planning items were complete among 70%, 78%, and 77% of DS respectively, but postdischarge items were complete among only 57%. Examining individual items, the lowest completion rates were found for test result follow‐up (42%), caregiver information (10%), and home services (64%), as well for assessment at admission and discharge of cognitive and mental status (56% and 53% respectively) and functional status (57% and 40%). Of note, all these items are of particular importance to geriatric care.

After receiving the audit and feedback intervention, fellows were more likely to complete all required discharge summary data when compared to prior‐to‐feedback (91% vs. 71%, P 0.001). Discharge summary completeness improved for all composite outcomes examining the four domains of care: admission (93% vs. 70%, P 0.001), hospital course (93% vs. 78%, P 0.001), discharge planning (93% vs. 77%, P 0.02), and postdischarge care (83% vs. 57%., P 0.001) (Table 1).

Discussion

Our study found that audit and feedback sessions significantly improved the completeness of DS dictated by geriatric medicine fellows at 1 academic medical center. Before feedback, completeness was high in most traditional areas of the DS including admission data, hospital course, and discharge planning, but was low in other areas critical for safe transitions of older adults such as postdischarge care, test follow‐up, caregiver information, and cognitive and functional status changes. These findings were surprising, as using a template should render a completion rate close to 100%. Notably, during feedback sessions, fellows suggested low completion rates were due to lack of awareness regarding the importance of completing all 21 items of the template and missing documentation in patient medical records.

Feedback sessions dramatically improved overall completeness of subsequent DS and in most of areas of specific importance for geriatric care, although we remain uncertain why all areas did not show improvement (for example, caregiver information completion remained low). One possible explanation is the lack of accurate documentation for all necessary items in the hospital medical record. Moreover, we did not observe completion improvement for other items, ie, diet and activity. Overall, we believe that drawing attention to areas of particular importance to geriatric care transitions and providing learners with individual reports on their performance increased their awareness and motivated changes to their practice, improving discharge summary completion.

Our study has limitations. This study was a pilot intervention without a control group, because of time and budgetary constraints. Also, we were unable to assess for sustainability because the fellows studied for this project graduated after the second audit. Third, we studied discharge summary completion; further research should focus on accuracy of discharge summary content. Finally, while we did not use any advanced technologies or materials, faculty time required to conduct the audit and feedback in this study was estimated at 45 hours. In our opinion this estimate would classify our audit and feedback intervention as a low external cost and moderately‐high human cost intervention, which may represent a potential barrier to generalizability. On the other hand, we believe that even an audit of a small sample of DS done by a physician could provide valuable data for feedback and would involve less faculty time.

Our finding that audit and feedback sessions improved the completeness of DS among house‐staff is important for 2 reasons. First, we were able to demonstrate that focused feedback targeted to areas of particular importance to the transition of older adults changed subsequent behavior and resulted in improved documentation of these areas. Second, our study provides evidence of a programmatic approach to address the ACGME competency of practice‐based learning and improvement. We believe that our intervention can be reproduced by training programs across the country and are hopeful that such interventions will result in improved patient outcomes during critical care transitions such as hospital discharge.

Discharge summaries (DS) correlate with rates of rehospitalization1, 2 and adverse events after discharge.3 The Joint Commission on the Accreditation of Healthcare Organizations acknowledges their importance and mandates that certain elements be included.4 Thus far, however, DS are not standardized across institutions and there is no expectation that they be available at postdischarge visits. There have been numerous attempts to improve the quality of DS by using more structured formats or computer generated summaries with positive results in term of comprehensiveness, clarity, and practitioner satisfaction58 but with persistence of serious errors and omissions.9

Postgraduate training is often the first opportunity for physicians to learn information transfer management skills. Unfortunately, DS are created by house staff who have minimal training in this area¹¹ and feel like they have to learn by osmosis,12 resulting in poor quality DS and lack of availability at the point of care.1315

Previous research suggested that individualized feedback sessions for Internal Medicine residents improved the quality of certain aspects of their completed DS.10 We postulated that an audit and feedback educational intervention on DS for first year geriatric medicine fellows would also improve their quality. This technique involves chart or case review of clinical practice behaviors for a specific task followed by recommendation of new behaviors when applicable.16 Audit and feedback incorporates adult learning theory,1719 an essential part of continuous quality improvement that fits within the Accreditation Council for Graduate Medical Education (ACGME) competency of practice based learning and improvement,20 as an educational activity.

Methods

Intervention

Audit #1

All available DS for each fellow's first month of inpatient service were audited for completeness of the 21 item discharge summary template by 1 author (AD). The 21 items were focused on 4 distinct periods of the hospitalization: admission, hospital course, discharge planning, and postdischarge care (Figure 1).

Figure 1

Content under each of the 21 items was classified as complete, partially complete, or absent. An item was considered complete if most information was present and appropriate medical terms were used, partially complete if information was unclear, and absent if no information was present for that area of the DS. To ensure investigator reliability, a random sample of 25% of each fellow's DS was scored by 2 additional investigators (RK and HF) and all disagreements were reviewed and resolved by consensus.

Feedback

Between December 2006 and January 2007, one‐on‐one formative feedback sessions were scheduled. The sessions were approximately 30 minutes long, confidential, performed by 1 of the authors (AD) and followed a written format. During these sessions, each fellow received the results of their discharge summary audit, each partially complete or absent item was discussed, and the importance of DS was emphasized.

Audit #2

All available DS for each fellow's second month of inpatient service were audited for completeness, using the same 21 item assessment tool and the same scoring system.

Results

Five fellows participated, 4 of whom were women; 2 were in postgraduate year 4, 3 in year 5. A total of 158 DS were audited, 89 prefeedback and 79 postfeedback. Each fellow dictated an average of 17 DS during each inpatient month.

During Audit #1, the 21 item DS were complete among 71%, incomplete among 18%, absent among 11%. Admission items, hospital course items, and discharge planning items were complete among 70%, 78%, and 77% of DS respectively, but postdischarge items were complete among only 57%. Examining individual items, the lowest completion rates were found for test result follow‐up (42%), caregiver information (10%), and home services (64%), as well for assessment at admission and discharge of cognitive and mental status (56% and 53% respectively) and functional status (57% and 40%). Of note, all these items are of particular importance to geriatric care.

After receiving the audit and feedback intervention, fellows were more likely to complete all required discharge summary data when compared to prior‐to‐feedback (91% vs. 71%, P 0.001). Discharge summary completeness improved for all composite outcomes examining the four domains of care: admission (93% vs. 70%, P 0.001), hospital course (93% vs. 78%, P 0.001), discharge planning (93% vs. 77%, P 0.02), and postdischarge care (83% vs. 57%., P 0.001) (Table 1).

Discussion

Our study found that audit and feedback sessions significantly improved the completeness of DS dictated by geriatric medicine fellows at 1 academic medical center. Before feedback, completeness was high in most traditional areas of the DS including admission data, hospital course, and discharge planning, but was low in other areas critical for safe transitions of older adults such as postdischarge care, test follow‐up, caregiver information, and cognitive and functional status changes. These findings were surprising, as using a template should render a completion rate close to 100%. Notably, during feedback sessions, fellows suggested low completion rates were due to lack of awareness regarding the importance of completing all 21 items of the template and missing documentation in patient medical records.

Feedback sessions dramatically improved overall completeness of subsequent DS and in most of areas of specific importance for geriatric care, although we remain uncertain why all areas did not show improvement (for example, caregiver information completion remained low). One possible explanation is the lack of accurate documentation for all necessary items in the hospital medical record. Moreover, we did not observe completion improvement for other items, ie, diet and activity. Overall, we believe that drawing attention to areas of particular importance to geriatric care transitions and providing learners with individual reports on their performance increased their awareness and motivated changes to their practice, improving discharge summary completion.

Our study has limitations. This study was a pilot intervention without a control group, because of time and budgetary constraints. Also, we were unable to assess for sustainability because the fellows studied for this project graduated after the second audit. Third, we studied discharge summary completion; further research should focus on accuracy of discharge summary content. Finally, while we did not use any advanced technologies or materials, faculty time required to conduct the audit and feedback in this study was estimated at 45 hours. In our opinion this estimate would classify our audit and feedback intervention as a low external cost and moderately‐high human cost intervention, which may represent a potential barrier to generalizability. On the other hand, we believe that even an audit of a small sample of DS done by a physician could provide valuable data for feedback and would involve less faculty time.

Our finding that audit and feedback sessions improved the completeness of DS among house‐staff is important for 2 reasons. First, we were able to demonstrate that focused feedback targeted to areas of particular importance to the transition of older adults changed subsequent behavior and resulted in improved documentation of these areas. Second, our study provides evidence of a programmatic approach to address the ACGME competency of practice‐based learning and improvement. We believe that our intervention can be reproduced by training programs across the country and are hopeful that such interventions will result in improved patient outcomes during critical care transitions such as hospital discharge.

Discharge summaries (DS) correlate with rates of rehospitalization1, 2 and adverse events after discharge.3 The Joint Commission on the Accreditation of Healthcare Organizations acknowledges their importance and mandates that certain elements be included.4 Thus far, however, DS are not standardized across institutions and there is no expectation that they be available at postdischarge visits. There have been numerous attempts to improve the quality of DS by using more structured formats or computer generated summaries with positive results in term of comprehensiveness, clarity, and practitioner satisfaction58 but with persistence of serious errors and omissions.9

Postgraduate training is often the first opportunity for physicians to learn information transfer management skills. Unfortunately, DS are created by house staff who have minimal training in this area¹¹ and feel like they have to learn by osmosis,12 resulting in poor quality DS and lack of availability at the point of care.1315

Previous research suggested that individualized feedback sessions for Internal Medicine residents improved the quality of certain aspects of their completed DS.10 We postulated that an audit and feedback educational intervention on DS for first year geriatric medicine fellows would also improve their quality. This technique involves chart or case review of clinical practice behaviors for a specific task followed by recommendation of new behaviors when applicable.16 Audit and feedback incorporates adult learning theory,1719 an essential part of continuous quality improvement that fits within the Accreditation Council for Graduate Medical Education (ACGME) competency of practice based learning and improvement,20 as an educational activity.

Methods

Intervention

Audit #1

All available DS for each fellow's first month of inpatient service were audited for completeness of the 21 item discharge summary template by 1 author (AD). The 21 items were focused on 4 distinct periods of the hospitalization: admission, hospital course, discharge planning, and postdischarge care (Figure 1).

Figure 1

Content under each of the 21 items was classified as complete, partially complete, or absent. An item was considered complete if most information was present and appropriate medical terms were used, partially complete if information was unclear, and absent if no information was present for that area of the DS. To ensure investigator reliability, a random sample of 25% of each fellow's DS was scored by 2 additional investigators (RK and HF) and all disagreements were reviewed and resolved by consensus.

Feedback

Between December 2006 and January 2007, one‐on‐one formative feedback sessions were scheduled. The sessions were approximately 30 minutes long, confidential, performed by 1 of the authors (AD) and followed a written format. During these sessions, each fellow received the results of their discharge summary audit, each partially complete or absent item was discussed, and the importance of DS was emphasized.

Audit #2

All available DS for each fellow's second month of inpatient service were audited for completeness, using the same 21 item assessment tool and the same scoring system.

Results

Five fellows participated, 4 of whom were women; 2 were in postgraduate year 4, 3 in year 5. A total of 158 DS were audited, 89 prefeedback and 79 postfeedback. Each fellow dictated an average of 17 DS during each inpatient month.

During Audit #1, the 21 item DS were complete among 71%, incomplete among 18%, absent among 11%. Admission items, hospital course items, and discharge planning items were complete among 70%, 78%, and 77% of DS respectively, but postdischarge items were complete among only 57%. Examining individual items, the lowest completion rates were found for test result follow‐up (42%), caregiver information (10%), and home services (64%), as well for assessment at admission and discharge of cognitive and mental status (56% and 53% respectively) and functional status (57% and 40%). Of note, all these items are of particular importance to geriatric care.

After receiving the audit and feedback intervention, fellows were more likely to complete all required discharge summary data when compared to prior‐to‐feedback (91% vs. 71%, P 0.001). Discharge summary completeness improved for all composite outcomes examining the four domains of care: admission (93% vs. 70%, P 0.001), hospital course (93% vs. 78%, P 0.001), discharge planning (93% vs. 77%, P 0.02), and postdischarge care (83% vs. 57%., P 0.001) (Table 1).

Discussion

Our study found that audit and feedback sessions significantly improved the completeness of DS dictated by geriatric medicine fellows at 1 academic medical center. Before feedback, completeness was high in most traditional areas of the DS including admission data, hospital course, and discharge planning, but was low in other areas critical for safe transitions of older adults such as postdischarge care, test follow‐up, caregiver information, and cognitive and functional status changes. These findings were surprising, as using a template should render a completion rate close to 100%. Notably, during feedback sessions, fellows suggested low completion rates were due to lack of awareness regarding the importance of completing all 21 items of the template and missing documentation in patient medical records.

Feedback sessions dramatically improved overall completeness of subsequent DS and in most of areas of specific importance for geriatric care, although we remain uncertain why all areas did not show improvement (for example, caregiver information completion remained low). One possible explanation is the lack of accurate documentation for all necessary items in the hospital medical record. Moreover, we did not observe completion improvement for other items, ie, diet and activity. Overall, we believe that drawing attention to areas of particular importance to geriatric care transitions and providing learners with individual reports on their performance increased their awareness and motivated changes to their practice, improving discharge summary completion.

Our study has limitations. This study was a pilot intervention without a control group, because of time and budgetary constraints. Also, we were unable to assess for sustainability because the fellows studied for this project graduated after the second audit. Third, we studied discharge summary completion; further research should focus on accuracy of discharge summary content. Finally, while we did not use any advanced technologies or materials, faculty time required to conduct the audit and feedback in this study was estimated at 45 hours. In our opinion this estimate would classify our audit and feedback intervention as a low external cost and moderately‐high human cost intervention, which may represent a potential barrier to generalizability. On the other hand, we believe that even an audit of a small sample of DS done by a physician could provide valuable data for feedback and would involve less faculty time.

Our finding that audit and feedback sessions improved the completeness of DS among house‐staff is important for 2 reasons. First, we were able to demonstrate that focused feedback targeted to areas of particular importance to the transition of older adults changed subsequent behavior and resulted in improved documentation of these areas. Second, our study provides evidence of a programmatic approach to address the ACGME competency of practice‐based learning and improvement. We believe that our intervention can be reproduced by training programs across the country and are hopeful that such interventions will result in improved patient outcomes during critical care transitions such as hospital discharge.

If you wish to receive credit for this activity, which beginson the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which beginson the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which beginson the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

Nosocomial, or hospital‐acquired, infections (HAIs) are a major cause of patient morbidity and mortality in the United States and other countries.15 In 2002, approximately 1.7 million HAIs occurred in US hospitals and were associated with an estimated 98,987 deaths.1 Of particular note, increasing percentages of HAIs are now caused by antimicrobial‐resistant pathogens, which have been linked with increases in morbidity, mortality, length of hospital stay, and healthcare costs.6

The 2004 data summary from the United States National Nosocomial Infections Surveillance (NNIS) System Report highlighted substantial increases for year 2003 versus 1998 through 2002 in vancomycin‐resistant enterococci (VRE); methicillin‐resistant Staphylococcus aureus; Klebsiella pneumoniae resistant to third‐generation cephalosporins; and Pseudomonas aeruginosa resistant to imipenem, quinolones, or third‐generation cephalosporins.7 Other gram‐negative bacteria of concern include Escherichia coli and Acinetobacter baumannii, as well as Enterobacter cloacae and E. aerogenes.8, 9

The increasing number of multidrug‐resistant (MDR) gram‐negative bacteria within the healthcare setting is particularly concerning.1013 Too frequently, clinicians in the United States now encounter gram‐negative bacteria species that are resistant to many, and occasionally all, currently available antibiotics. For many of these MDR gram‐negative pathogens the antimicrobials that potentially remain active (eg, aminoglycosides and polymyxins) are often more toxic and less efficacious for some infections.14 Particularly problematic is that the pharmaceutical industry's developmental pipeline for new antibiotics, with novel mechanisms of action that might be used against MDR gram‐negative pathogens, has virtually come to a standstill.15, 16 Even if an investigational drug was in phase 2 or 3 trials right now or entered the US Food and Drug Administration (FDA) Fast Track Development Program, it would be at least 10 or 15 years before that drug would be available on the US market.

What this means is that the clinician's current antibiotic armamentarium is all they can expect in the foreseeable future. It also means that special care needs to be taken to optimally use currently available agents to ensure continued activity against the pathogens encountered in the hospital (and community) setting, now and in the future. Maximizing clinical outcomes, while minimizing the emergence and spread of antimicrobial resistance (and other adverse effects associated with suboptimal antimicrobial drug use), falls under the purview of antimicrobial stewardship, the focus of this paper.

Antimicrobial StewardshipWhy Is It Needed, What Is It, and What Are Its Goals?

Constructing an Antimicrobial Stewardship Program

A Case Study: the Wake Forest University Baptist Medical Center (WFUBMC) Program

Figure 1A,B provides an overview of the general structure of the antimicrobial stewardship program at WFUBMC implemented in 2000. To establish and provide the information needed for day‐to‐day operations of a stewardship program at WFUBMC, data are needed on how, where, and by whom antibiotics are used within the institution. In addition, microbiology data, including the frequency and susceptibility of infecting pathogens, are essential. Obtaining these data often requires the help and cooperation of the information technology (IT) staff at the institution. Considerable time and effort may be required at the outset, but once information system programs are established, ongoing data mining is much easier. At the time of program initiation, it was decided to assess antibiotic use or density (amount of drug per inpatient geographic unit) using the defined‐daily‐dose (DDD) method. This entails assigning a predetermined weight of administered antibiotic as a dose and dividing by a denominator of 1000 patient days. Subsequently, days of therapy per drug has been found to be a more accurate measure of antimicrobial consumption. When developing a program, it is vital to first obtain baseline usage data. Such data should include, if possible, a detailed inventory of usage within different units of the hospital or for particular services, or sometimes even for a particular provider with a history of high antimicrobial usage. Ongoing measurement over time allows the impact of new stewardship interventions and guidelines to be measured, as well as identifying potential new problem areas in usage.

Figure 1

Good microbiology data are also essential to determine problem pathogens at the institution and where they are located. Such data are useful not only to define areas of resistance (potentially warranting changes in antimicrobial policies to alter selection pressures), but also for gathering information necessary for defining local guidelines for antimicrobial use. For example, if the local antibiograms show that a particular pathogen in the hospital ICU has a particular resistance pattern, then initial empiric therapy for patients at risk of infection with those organisms should be chosen to cover the problematic resistant pathogen. Once subsequent microbiology data become available, patients not infected with the pathogen can be de‐escalated to a more narrow‐spectrum antibiotic.

As illustrated in Figure 1A, at WFUBMC, all the collected data are integrated to provide information concerning antibiotic density, usage, and patterns of antimicrobial resistance. This information is received by the staff of the antimicrobial stewardship program, which at WFUBMC is called the Center for Antimicrobial Utilization, Stewardship and Epidemiology (CAUSE). The CAUSE staff works with the day‐to‐day elements of program administration and operations and includes 2 infectious diseases physicians and 2 infectious disease PharmDs. The CAUSE staff works very closely with the microbiology laboratory, hospital pharmacy, and the medical director of hospital epidemiology and infection control.

The CAUSE program at WFUBMC administratively functions through an advisory board committee that includes thought leaders from different medical specialties and patient units of the hospitalparticularly those with high antimicrobial usage, such as hematology/oncology, pulmonary, critical care, and transplantation. The CAUSE staff and advisory board exist to exchange ideas concerning what is working or not working and where problem areas may be, and to propose possible changes in antimicrobial practices at the institution. In addition, thought leaders on the advisory board also receive and evaluate information from various sources about new antimicrobial agents and national guidelines, and, in turn, help disseminate this information to the hospital personnel who will be involved in program implementation.

At WFUBMC, it is the advisory board committee, working in conjunction with the CAUSE staff/medical director, that presents antimicrobials for formulary consideration to the Pharmacy and Therapeutics (P&T) Committee, in addition to any major interventions CAUSE and its advisory board feel are indicated. The P&T committee then reports to the medical staff executive committee and hospital leadership. As should be evident, the approach to stewardship at WFUBMC is medical staff‐driven, rather than a function of administrative constituents.

Finally, no matter how well‐organized an antimicrobial stewardship program is, it will not be fully successful if the entire medical staff does not buy into the process and agree with the need for the proposed changes and interventions involving the practice of antimicrobial therapy. It is important to spend some time early in program development to ensure that the need for an antimicrobial stewardship program, the process, and the outcomes (both in terms of patient care and clinical outcomes at the institution) are clearly communicated to the medical staff, and that their full commitment and cooperation are enlisted. In cases where hospital‐wide infection or resistance rates are known and antimicrobial utilization data are available, it is important to present such information in an understandable and convincing manner that makes the case for a proposed change or intervention, not only at the hospital level but also at the level of the patient.

Elements of a Successful Program: Basic Strategies

Potential strategies or elements of an antimicrobial stewardship program are listed in Table 2. Two evidence‐based fundamental or core strategies have been recommended by the IDSA/SHEA guidelines24 and implemented at numerous institutions with various levels of success. The first is a so‐called back‐end approach to modifying antimicrobial therapy on the basis of prospective audit of antimicrobial use, with intervention and feedback to the provider. The second is a front‐end approach using formulary restriction and preauthorization requirements for specific antimicrobial agents. Various supplemental strategies, including large group and patient case‐based education, guidelines and clinical pathways, antimicrobial order forms, and computerized clinical decision support, are also recommended.

Prospective Audit With Intervention and Feedback

This approach usually involves the use of an antimicrobial support team that reviews initial or ongoing therapy and then intervenes to provide feedback and suggested modifications to the medical care provider to improve therapy. This can be done by an infectious diseases physician, a clinical pharmacist, or a hospitalist or internist with expertise in antimicrobial therapy. The aim is to provide patient‐specific education and/or suggest changes to antimicrobial utilization (when needed) to improve and streamline therapy. Suggested interventions could include discontinuing or changing 1 or more drugs, switching intravenous to oral drug administration, and suggesting a short‐course duration of therapy. Occasionally, suggestions are made when appropriate to actually escalate or intensify therapy to increase efficacy. Identification of patients for targeting or focusing prospective audit and feedback efforts typically involves using computer surveillance to single out problem antimicrobials or problematic usage, given local resistance patterns or patient characteristics.24 Examples could include a focus on asymptomatic bacteruria, excessive duration of therapy for ventilator‐associated pneumonia, or overzealous use of certain classes of antimicrobials. Another potential activity for a prospective audit and feedback team is to review reports of patient‐specific blood and sterile body fluid culture results matched to the patient's current antimicrobial therapy. This allows for daily review of the appropriateness of therapy for potentially serious infections. Some patients seen by the antibiotic support team may be referred for infectious diseases or other expert consultative opinion if their infections or therapy are felt to be too complicated for routine prospective audit and feedback recommendations.

A number of studies have demonstrated that strategies involving prospective audit with intervention and feedback can improve antibiotic stewardship, as measured by reductions in inappropriate antibiotic use,30 reduced antibiotic costs or overall consumption,3135 greater compliance with hospital treatment guidelines or policies33, 36, 37 and, in some cases, reduced number of infections due to C difficile infection32, 37 or resistant pathogens.31, 32, 37 Prospective audit with feedback is probably the best and most effective core strategy for a community hospital program where other interventions are cumbersome or not as well tolerated by the medical staff. One potential disadvantage of the prospective audit with intervention and feedback approach is that medical provider adherence is largely voluntary. The team can make suggestions, but if the provider disagrees or is unobtainable, the suggestion is never implemented. Also, this strategy can also be resource‐intensive from a personnel perspective.

Evaluating Antimicrobial Stewardship Programs

Two general types of measures are used to evaluate the effectiveness of antimicrobial stewardship: process and outcome. As with most things done in the hospital, process measures are easier. They measure surrogate impacts of a program, accountability, resource use, and cost effectiveness. In essence, process measures evaluate whether the program accomplished what it set out to do in terms of changing certain processes or prescriber behaviors. It is important to measure resource use, as this helps to continue funding and to keep workers involved in the project. Good programs will save money; this can easily be measured, even if it is just as simple as going to the hospital pharmacy and looking at the cost of antimicrobials provided per patient day.

Outcomes like decreases in particular infections, less emergence of antimicrobial resistance, or other patient‐specific measures are likely more important in the big picture, but they are also much more difficult to measure. For example, where one would like to measure changes in pathogen resistance after making some changes in antimicrobial stewardship, it often takes years before the benefits of a particular intervention or change materialize in terms of less resistance or reduced emergence of resistance. If that type of change is to be measured, then one needs to be persistent and continue measurements over a long period of time. In addition, given the protracted amount of time before these outcomes may be observed, a number of other changes are likely to happen that coincide with the antimicrobial stewardship interventions and make assessment of causality difficult and biased.

Having said that, a number of studies have demonstrated a relationship between antibiotic restriction48, 8285 or other antimicrobial stewardship policies32, 86 and decreases in nosocomial C difficile infections or disease. Figure 2 illustrates the impact of a nonrestrictive antimicrobial stewardship program at a secondary/tertiary‐care hospital in Quebec, Canada, on an epidemic of C difficileassociated disease (CDAD) that occurred at the institution during the latter portion of 2003.86 Following program implementation, and the major drop in targeted antibiotic consumption, the incidence of CDAD also significantly decreased. Earlier implementation of infection control measures had no effect on CDAD incidence.

Figure 2

A smaller number of studies have reported decreases in resistant gram‐negative bacteria following implementation of antimicrobial stewardship programs. For example, Meyer and colleagues reported a marked reduction in ceftazidime‐resistant K pneumoniae at a 487‐bed general hospital in New York City after implementation of enhanced ceftazidime restriction and barrier precautions following an outbreak of infections caused by the resistant K pneumoniae.87 Similarly, Carling and coworkers reported a significant decrease in nosocomial infections caused by resistant Enterobacteriaceae following implementation of a multidisciplinary antibiotic stewardship program to minimize inappropriate use of third‐generation cephalosporins (Figure 3).32 More recently, a retrospective, longitudinal, multicenter analysis of a consortium of 22 academic health centers in the United States showed that incidence rates of carbapenem‐resistant P aeruginosa were lower at hospitals that restricted carbapenems than those that did not (P = .01).88

Figure 3

Evidence suggesting a beneficial impact of antimicrobial stewardship programs on resistance in gram‐positive organisms is limited. More specifically, the study by Carling and colleagues reported an apparent decrease in VRE rates following implementation of their program to reduce inappropriate use of third‐generation cephalosporins.32 The hospital had VRE rates similar to other NNIS System hospitals prior to beginning the program, but after antibiotic stewardship measures were implemented, the VRE rate began to drop, falling to 6% by 1999. This should be compared with a VRE rate of 24% for similar NNIS System hospitals in 1999.

As far as reducing healthcare costs, Figure 4A illustrates the direct antimicrobial cost savings at WFUBMC after implementation of the CAUSE antimicrobial stewardship program, and Figure 4B after supplemental interventions were implemented. Although decreasing antimicrobial cost is important, one would like to show decreases in overall healthcare costs associated with an antimicrobial stewardship program. Unfortunately, this is often a little more difficult to demonstrate. Extrapolations, however, may be possible. Because antimicrobial resistance, adverse drug effects, and secondary unintended infections such as C difficile colitis have been linked with increased patient morbidity and mortality, longer hospital stays, and increased healthcare costs,6, 89, 90 improved antimicrobial stewardship is expected to optimize patient care and lower overall healthcare costs. A study in a large tertiary care academic medical center estimated more than $4.25 million in total healthcare savings over 1 year with a stewardship program using both preauthorization and, to a lesser extent, prospective audit and feedback.91 Despite the fact cost saving should not be a primary goal of an antimicrobial stewardship program, lower antimicrobial costs can help keep a program funded and buttress a proposal for an antimicrobial stewardship program to hospital leadership.

Figure 4

Many hospitals recognize other areas where an antimicrobial stewardship program can demonstrate its value. This includes implementation of a rapid change in drug utilization during antimicrobial supply shortages and assistance with regulatory mandates and surgical infection prophylaxis. Stewardship teams often assist microbiology with protocols for microbiology reporting, antibiograms, planning for susceptibility testing, and communicating changes in microbiology tests or protocols to clinicians.

Conclusions

Overuse or misuse of antibiotics and other antimicrobials for hospital inpatients is relatively common, and can be associated with several unintended negative consequences. Improving medical care necessarily includes better use of antimicrobials to optimize outcomes and preserve the effectiveness of currently available agents. Further, an important additional consequence of effective antimicrobial stewardship and improved patient care is typically a lowering of overall healthcare costs. The recent 2007 IDSA/SHEA guidelines provide recommendations for developing an institutional program to enhance antimicrobial stewardship. However, individual institutions need to look closely at their own systems and patients to develop an antimicrobial stewardship program that best serves the needs of their hospital and the people it serves.