Postfellowship Pathways

 

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

Up to this point, no week seems to be like the one before! A typical week could involve addressing any patient safety events and creating system-safety solutions to prevent them in the future. There will be meetings concerning ongoing quality improvement initiatives such as sepsis care, readmissions, and hospital-acquired infections. Each week, there will be a handful of patient grievances that will need to be addressed. I see patients a few hours a week and some weeks include teaching in the medical school or with housestaff at our larger campus. I visit the floors or our outpatient practices a few times to interact with frontline staff as well as patients to hear how things are working.
 

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

 

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

 

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

Up to this point, no week seems to be like the one before! A typical week could involve addressing any patient safety events and creating system-safety solutions to prevent them in the future. There will be meetings concerning ongoing quality improvement initiatives such as sepsis care, readmissions, and hospital-acquired infections. Each week, there will be a handful of patient grievances that will need to be addressed. I see patients a few hours a week and some weeks include teaching in the medical school or with housestaff at our larger campus. I visit the floors or our outpatient practices a few times to interact with frontline staff as well as patients to hear how things are working.
 

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

 

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

 

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

Up to this point, no week seems to be like the one before! A typical week could involve addressing any patient safety events and creating system-safety solutions to prevent them in the future. There will be meetings concerning ongoing quality improvement initiatives such as sepsis care, readmissions, and hospital-acquired infections. Each week, there will be a handful of patient grievances that will need to be addressed. I see patients a few hours a week and some weeks include teaching in the medical school or with housestaff at our larger campus. I visit the floors or our outpatient practices a few times to interact with frontline staff as well as patients to hear how things are working.
 

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

 

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

 

What led you to pursue a career in medical education?

Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

What do you enjoy most about working in medical education?

There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.

What are your responsibilities in a typical week?

One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.

Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
 

What are the different career options available for early-career GIs who are interested in medical education?

There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.

The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.^1,2

 

Are there advanced training options available for those interested in medical education?

The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)³ is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW^®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.⁴ One group was successful in publishing an educational article after completing the Future Leaders program.⁵ There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.

How do you go about finding a job in medical education?

First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.

It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
 

What are the resources available to early-career GIs interested in medical education?

It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.^6,7

Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
 

Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.

References

1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.

2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.

3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.

4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.

5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.

6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.

7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
 

 

What led you to pursue a career in medical education?

Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

What do you enjoy most about working in medical education?

There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.

What are your responsibilities in a typical week?

One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.

Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
 

What are the different career options available for early-career GIs who are interested in medical education?

There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.

The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.^1,2

 

Are there advanced training options available for those interested in medical education?

The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)³ is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW^®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.⁴ One group was successful in publishing an educational article after completing the Future Leaders program.⁵ There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.

How do you go about finding a job in medical education?

First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.

It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
 

What are the resources available to early-career GIs interested in medical education?

It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.^6,7

Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
 

Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.

References

1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.

2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.

3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.

4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.

5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.

6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.

7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
 

 

What led you to pursue a career in medical education?

Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

What do you enjoy most about working in medical education?

There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.

What are your responsibilities in a typical week?

One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.

Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
 

What are the different career options available for early-career GIs who are interested in medical education?

There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.

The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.^1,2

 

Are there advanced training options available for those interested in medical education?

The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)³ is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW^®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.⁴ One group was successful in publishing an educational article after completing the Future Leaders program.⁵ There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.

How do you go about finding a job in medical education?

First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.

It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
 

What are the resources available to early-career GIs interested in medical education?

It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.^6,7

Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
 

Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.

References

1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.

2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.

3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.

4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.

5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.

6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.

7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
 

 

What is a GI hospitalist?

A GI hospitalist is a gastroenterologist that primarily provides inpatient care. Their main professional focus is the acute management of gastrointestinal conditions occurring in the hospital setting.

How prevalent are subspecialty hospitalists?

The rise of hospitalists has changed the landscape of medicine. The hospitalist is now the central inpatient provider responsible for patient care and day-to-day housestaff education. From 1995 to 2016, the number of hospitalists increased from 500 to over 50,000.¹ While the majority of hospitalists are generalists from the fields of internal medicine, pediatrics, and obstetrics/gynecology, some come in the form of specialists. In a recent survey, up to 10% of internal medicine subspecialists already consider themselves “hospitalists.”² However, most of these self-described hospitalists only do so part of the time. For example, many group practices have one of their members manage all the hospitalized patients for the group for certain periods of time. It is rare to find full-time subspecialist hospitalists, but there has been an emergence in this new model of GI practice. Many people are unaware of this system of care nor understand how it may influence hospital-based care.

What is the role of a GI hospitalist?

As for every physician, an individual’s responsibilities vary widely. It depends on a host of factors. Your role depends on the size of the team and hospital that you are responsible for. You may be part of a large group multispecialty practice or a GI physician group or work for a tertiary academic center as I do. As such, your team may consist of nurse practitioners, physician assistants, GI fellows, or your partners. Some GI practices alternate different members to cover the group’s hospitalized patients for fixed periods of time. On the other hand, some GI practices or divisions hire dedicated full-time GI hospitalists.

While my primary responsibility is to care for inpatients whom require GI consults, I have outpatient and administrative responsibilities. Generally speaking, I am the de facto consult attending for the year.
 

How did you decide to become a GI hospitalist?

Upon graduation from my GI fellowship, I wanted an academic job where I could work closely with fellows and manage a wide breadth of complex, high-acuity patients. During fellowship, I enjoyed all areas of gastroenterology and hepatology and did not “sub-subspecialize.” As such, I wanted a job where I would see the full spectrum of GI and liver disease. Additionally, I enjoyed seeing the sickest patients, because I felt I could make the most dramatic differences with my care.

When I was searching for jobs, I spoke with the chief of GI at the hospital where I completed my residency about how I could fill a niche. We conceived of a model that would merge my personal interests and help the division provide consistent teaching for fellows and increase inpatient billing. Prior to my arrival, attendings that staffed the consult service were expected to continue their research and outpatient clinical workload while finding time to come to the hospital. Not surprisingly, attending rounds was erratic. The fellows were left to manage patients independently, scrambled to run cases by whomever happened to be around, or waited until they could reach the attending the next day. Unsurprisingly, billing by attendings was sparse.
 

What is a typical day like in your life as a GI hospitalist?

My day starts at 7:30 a.m. either with my outpatient office hours, endoscopy session, or GI Grand Rounds. Each week, I have two morning outpatient office sessions, one morning endoscopy session, and one morning session supervising fellows’ endoscopy.

At noon, I round with a team of GI fellows, medical students, and housestaff rotators for 2 hours. After we see the new consults, the remainder of my afternoon is spent seeing the follow-up patients. For two afternoons throughout the week, I have outpatient endoscopy sessions. I typically conclude my day at 5 p.m.

For night coverage, I take emergency calls for my own patients, and share general call duties with the other members of my division. On average, I take calls for one weekday a month and five weekends per year.

Typically, GI hospitalists only cover inpatients during the daytime. All nights and weekends are covered by partners and nonemergent overnight consults are saved until the next day. They have no office work.
 

What is the most challenging part of being a GI hospitalist?

As the perpetual “GI Consult Attending,” there is the threat of burnout when confronted with a high volume of sick, complex patients. Many of the patients have multiple comorbidities and require a multidisciplinary approach. On average, we have five new consults a day and the number of active follow-up patients is 10. Nonetheless, the nature of the inpatient service makes the volume of work unpredictable. When the service is busy and the census swells, the numbers of patients requiring staffing and notes can become overwhelming.

 

Mike Powell/Thinkstock

While there is diversity in the types of consults, one repeatedly confronts common problems such as GI bleeding, food impactions, unexplained abdominal pain, diarrhea, dysphagia, nausea and vomiting, iron-deficiency anemia, abnormal liver tests, and PEG placements. Seeing the same consults over and over again can get tiresome. Fortunately, in a teaching hospital, this repetition is somewhat mitigated when one’s audience consists of new crops of enthusiastic medical students, rotating housestaff, and fellows.

Importantly, for those without an outpatient practice, one loses the opportunity to develop longitudinal relationships with patients. Additionally, one also loses the ability to provide integrated, comprehensive care for individual patients once they leave the hospital.
 

How are you paid?

My compensation is based on a base salary with an incentivized system based on my RVUs and collections. For the dedicated hospitalist for a group practice, there is typically a base salary and productivity-based income. Additionally, there should be a path to partnership. Lastly, in balancing the ledger, the diminished inpatient revenue stream is offset by the lack of overhead.

What are the benefits of a GI hospitalist system?

Our system benefits the workflow for the GI fellows. Since I have started, the GI consultation rounds start at a consistent time. During these rounds, we discuss relevant GI literature and make timely plans on all patients. Oftentimes, I am able to supervise the fellows so they can fit in a scope before the end of the workday. Ultimately, the fellows know they can find me and discuss patients throughout the day. The fellows consistently have told me that the since the implementation of the hospitalist system, there has been a dramatic difference. Collectively, they feel both their education and patient care have improved.

In terms of consult efficiency, one study demonstrated that the transition to a GI hospitalist system resulted in a mean decrease in consult to urgent esophagogastroduodenoscopy (EGD) time from approximately 24 to 14 hours.³ However, this occurred in the context of a lower inpatient consult volume and only covered 2 months. Furthermore, the time from admission to EGD did not change. Nonetheless, further studies are needed to examine the impact of this model shift.

In terms of a financial benefit, at our institution the total gross inpatient charges increased more than $850,000 for the year. This was largely attributable to the 79% increase in the gross charges from follow-up notes.

For group practices, the hospitalist system makes more efficient use of physician’s time. Physicians can either focus on outpatients or inpatients without worrying about going between the office, ambulatory surgical center, and the hospital. In general, inpatients require a disproportionate amount of time relative to the revenue collected. Furthermore, by eliminating the need for group physicians to go to the hospital, they can carve out 1-2 hours of office time to increase billing.

When there is one point-person whom handles all inpatient GI, communication is facilitated among primary teams and other services. The GI hospitalist develops working relationships with surgeons, radiologists, anesthesiologists, intensivists, etc. Teams can often just text or call me directly, instead of looking for the covering attending or going through the office phone service.
 

What are drawbacks to the GI hospitalist model?

Since there is only one gastroenterologist in the hospitalist model, if that person is not doing a good job, it affects the management of GI conditions for the entire hospital.

There is a loss of continuity-of-care. When GI patients get admitted, the gastroenterologists responsible for their care will not be the person with whom they have a long-term relationship. Furthermore, when the patient gets discharged, the primary gastroenterologists will not be fully aware of the inpatient course.

Also, when outpatient and inpatient gastroenterologists become segregated based on hospital setting, they each lose out of learning the intricacies of managing patients in a different context.
 

What do you like most about being a GI hospitalist?

The GI hospitalist position creates a great opportunity for gastroenterologists to make a remarkable, immediate impact on interesting, high acuity patients. The nature of the job also has the advantage of providing reasonable hours. This may be attractive to many whom want a better work-life balance.

Dr. Wan is assistant professor of medicine, associate program director, GI Fellowship Program, New York Presbyterian/Weill Cornell Medical Center, New York, N.Y.

References

1. Wachter R.M., Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Sep 15;375[11]:1009-11.

2. Estimating the Number and Characteristics of Hospitalist Physicians in the United States and Their Possible Workforce Implications. Analysis in Brief. Available at: https://www.aamc.org/download/300620/data/aibvol12_no3-hospitalist.pdf. Accessed May 1st, 2016.

3. Mahadev S., Lebwohl B., Ramirez I., Garcia-Carrasquillo R.J., Freedberg, D.E. Transition to a GI Hospitalist System is Associated with Expedited Upper Endoscopy. Gastroenterology. 2016;150[4]:S639-40.
 

 

What is a GI hospitalist?

A GI hospitalist is a gastroenterologist that primarily provides inpatient care. Their main professional focus is the acute management of gastrointestinal conditions occurring in the hospital setting.

How prevalent are subspecialty hospitalists?

The rise of hospitalists has changed the landscape of medicine. The hospitalist is now the central inpatient provider responsible for patient care and day-to-day housestaff education. From 1995 to 2016, the number of hospitalists increased from 500 to over 50,000.¹ While the majority of hospitalists are generalists from the fields of internal medicine, pediatrics, and obstetrics/gynecology, some come in the form of specialists. In a recent survey, up to 10% of internal medicine subspecialists already consider themselves “hospitalists.”² However, most of these self-described hospitalists only do so part of the time. For example, many group practices have one of their members manage all the hospitalized patients for the group for certain periods of time. It is rare to find full-time subspecialist hospitalists, but there has been an emergence in this new model of GI practice. Many people are unaware of this system of care nor understand how it may influence hospital-based care.

What is the role of a GI hospitalist?

As for every physician, an individual’s responsibilities vary widely. It depends on a host of factors. Your role depends on the size of the team and hospital that you are responsible for. You may be part of a large group multispecialty practice or a GI physician group or work for a tertiary academic center as I do. As such, your team may consist of nurse practitioners, physician assistants, GI fellows, or your partners. Some GI practices alternate different members to cover the group’s hospitalized patients for fixed periods of time. On the other hand, some GI practices or divisions hire dedicated full-time GI hospitalists.

While my primary responsibility is to care for inpatients whom require GI consults, I have outpatient and administrative responsibilities. Generally speaking, I am the de facto consult attending for the year.
 

How did you decide to become a GI hospitalist?

Upon graduation from my GI fellowship, I wanted an academic job where I could work closely with fellows and manage a wide breadth of complex, high-acuity patients. During fellowship, I enjoyed all areas of gastroenterology and hepatology and did not “sub-subspecialize.” As such, I wanted a job where I would see the full spectrum of GI and liver disease. Additionally, I enjoyed seeing the sickest patients, because I felt I could make the most dramatic differences with my care.

When I was searching for jobs, I spoke with the chief of GI at the hospital where I completed my residency about how I could fill a niche. We conceived of a model that would merge my personal interests and help the division provide consistent teaching for fellows and increase inpatient billing. Prior to my arrival, attendings that staffed the consult service were expected to continue their research and outpatient clinical workload while finding time to come to the hospital. Not surprisingly, attending rounds was erratic. The fellows were left to manage patients independently, scrambled to run cases by whomever happened to be around, or waited until they could reach the attending the next day. Unsurprisingly, billing by attendings was sparse.
 

What is a typical day like in your life as a GI hospitalist?

My day starts at 7:30 a.m. either with my outpatient office hours, endoscopy session, or GI Grand Rounds. Each week, I have two morning outpatient office sessions, one morning endoscopy session, and one morning session supervising fellows’ endoscopy.

At noon, I round with a team of GI fellows, medical students, and housestaff rotators for 2 hours. After we see the new consults, the remainder of my afternoon is spent seeing the follow-up patients. For two afternoons throughout the week, I have outpatient endoscopy sessions. I typically conclude my day at 5 p.m.

For night coverage, I take emergency calls for my own patients, and share general call duties with the other members of my division. On average, I take calls for one weekday a month and five weekends per year.

Typically, GI hospitalists only cover inpatients during the daytime. All nights and weekends are covered by partners and nonemergent overnight consults are saved until the next day. They have no office work.
 

What is the most challenging part of being a GI hospitalist?

As the perpetual “GI Consult Attending,” there is the threat of burnout when confronted with a high volume of sick, complex patients. Many of the patients have multiple comorbidities and require a multidisciplinary approach. On average, we have five new consults a day and the number of active follow-up patients is 10. Nonetheless, the nature of the inpatient service makes the volume of work unpredictable. When the service is busy and the census swells, the numbers of patients requiring staffing and notes can become overwhelming.

 

Mike Powell/Thinkstock

While there is diversity in the types of consults, one repeatedly confronts common problems such as GI bleeding, food impactions, unexplained abdominal pain, diarrhea, dysphagia, nausea and vomiting, iron-deficiency anemia, abnormal liver tests, and PEG placements. Seeing the same consults over and over again can get tiresome. Fortunately, in a teaching hospital, this repetition is somewhat mitigated when one’s audience consists of new crops of enthusiastic medical students, rotating housestaff, and fellows.

Importantly, for those without an outpatient practice, one loses the opportunity to develop longitudinal relationships with patients. Additionally, one also loses the ability to provide integrated, comprehensive care for individual patients once they leave the hospital.
 

How are you paid?

My compensation is based on a base salary with an incentivized system based on my RVUs and collections. For the dedicated hospitalist for a group practice, there is typically a base salary and productivity-based income. Additionally, there should be a path to partnership. Lastly, in balancing the ledger, the diminished inpatient revenue stream is offset by the lack of overhead.

What are the benefits of a GI hospitalist system?

Our system benefits the workflow for the GI fellows. Since I have started, the GI consultation rounds start at a consistent time. During these rounds, we discuss relevant GI literature and make timely plans on all patients. Oftentimes, I am able to supervise the fellows so they can fit in a scope before the end of the workday. Ultimately, the fellows know they can find me and discuss patients throughout the day. The fellows consistently have told me that the since the implementation of the hospitalist system, there has been a dramatic difference. Collectively, they feel both their education and patient care have improved.

In terms of consult efficiency, one study demonstrated that the transition to a GI hospitalist system resulted in a mean decrease in consult to urgent esophagogastroduodenoscopy (EGD) time from approximately 24 to 14 hours.³ However, this occurred in the context of a lower inpatient consult volume and only covered 2 months. Furthermore, the time from admission to EGD did not change. Nonetheless, further studies are needed to examine the impact of this model shift.

In terms of a financial benefit, at our institution the total gross inpatient charges increased more than $850,000 for the year. This was largely attributable to the 79% increase in the gross charges from follow-up notes.

For group practices, the hospitalist system makes more efficient use of physician’s time. Physicians can either focus on outpatients or inpatients without worrying about going between the office, ambulatory surgical center, and the hospital. In general, inpatients require a disproportionate amount of time relative to the revenue collected. Furthermore, by eliminating the need for group physicians to go to the hospital, they can carve out 1-2 hours of office time to increase billing.

When there is one point-person whom handles all inpatient GI, communication is facilitated among primary teams and other services. The GI hospitalist develops working relationships with surgeons, radiologists, anesthesiologists, intensivists, etc. Teams can often just text or call me directly, instead of looking for the covering attending or going through the office phone service.
 

What are drawbacks to the GI hospitalist model?

Since there is only one gastroenterologist in the hospitalist model, if that person is not doing a good job, it affects the management of GI conditions for the entire hospital.

There is a loss of continuity-of-care. When GI patients get admitted, the gastroenterologists responsible for their care will not be the person with whom they have a long-term relationship. Furthermore, when the patient gets discharged, the primary gastroenterologists will not be fully aware of the inpatient course.

Also, when outpatient and inpatient gastroenterologists become segregated based on hospital setting, they each lose out of learning the intricacies of managing patients in a different context.
 

What do you like most about being a GI hospitalist?

The GI hospitalist position creates a great opportunity for gastroenterologists to make a remarkable, immediate impact on interesting, high acuity patients. The nature of the job also has the advantage of providing reasonable hours. This may be attractive to many whom want a better work-life balance.

Dr. Wan is assistant professor of medicine, associate program director, GI Fellowship Program, New York Presbyterian/Weill Cornell Medical Center, New York, N.Y.

References

1. Wachter R.M., Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Sep 15;375[11]:1009-11.

2. Estimating the Number and Characteristics of Hospitalist Physicians in the United States and Their Possible Workforce Implications. Analysis in Brief. Available at: https://www.aamc.org/download/300620/data/aibvol12_no3-hospitalist.pdf. Accessed May 1st, 2016.

3. Mahadev S., Lebwohl B., Ramirez I., Garcia-Carrasquillo R.J., Freedberg, D.E. Transition to a GI Hospitalist System is Associated with Expedited Upper Endoscopy. Gastroenterology. 2016;150[4]:S639-40.
 

 

What is a GI hospitalist?

A GI hospitalist is a gastroenterologist that primarily provides inpatient care. Their main professional focus is the acute management of gastrointestinal conditions occurring in the hospital setting.

How prevalent are subspecialty hospitalists?

The rise of hospitalists has changed the landscape of medicine. The hospitalist is now the central inpatient provider responsible for patient care and day-to-day housestaff education. From 1995 to 2016, the number of hospitalists increased from 500 to over 50,000.¹ While the majority of hospitalists are generalists from the fields of internal medicine, pediatrics, and obstetrics/gynecology, some come in the form of specialists. In a recent survey, up to 10% of internal medicine subspecialists already consider themselves “hospitalists.”² However, most of these self-described hospitalists only do so part of the time. For example, many group practices have one of their members manage all the hospitalized patients for the group for certain periods of time. It is rare to find full-time subspecialist hospitalists, but there has been an emergence in this new model of GI practice. Many people are unaware of this system of care nor understand how it may influence hospital-based care.

What is the role of a GI hospitalist?

As for every physician, an individual’s responsibilities vary widely. It depends on a host of factors. Your role depends on the size of the team and hospital that you are responsible for. You may be part of a large group multispecialty practice or a GI physician group or work for a tertiary academic center as I do. As such, your team may consist of nurse practitioners, physician assistants, GI fellows, or your partners. Some GI practices alternate different members to cover the group’s hospitalized patients for fixed periods of time. On the other hand, some GI practices or divisions hire dedicated full-time GI hospitalists.

While my primary responsibility is to care for inpatients whom require GI consults, I have outpatient and administrative responsibilities. Generally speaking, I am the de facto consult attending for the year.
 

How did you decide to become a GI hospitalist?

Upon graduation from my GI fellowship, I wanted an academic job where I could work closely with fellows and manage a wide breadth of complex, high-acuity patients. During fellowship, I enjoyed all areas of gastroenterology and hepatology and did not “sub-subspecialize.” As such, I wanted a job where I would see the full spectrum of GI and liver disease. Additionally, I enjoyed seeing the sickest patients, because I felt I could make the most dramatic differences with my care.

When I was searching for jobs, I spoke with the chief of GI at the hospital where I completed my residency about how I could fill a niche. We conceived of a model that would merge my personal interests and help the division provide consistent teaching for fellows and increase inpatient billing. Prior to my arrival, attendings that staffed the consult service were expected to continue their research and outpatient clinical workload while finding time to come to the hospital. Not surprisingly, attending rounds was erratic. The fellows were left to manage patients independently, scrambled to run cases by whomever happened to be around, or waited until they could reach the attending the next day. Unsurprisingly, billing by attendings was sparse.
 

What is a typical day like in your life as a GI hospitalist?

My day starts at 7:30 a.m. either with my outpatient office hours, endoscopy session, or GI Grand Rounds. Each week, I have two morning outpatient office sessions, one morning endoscopy session, and one morning session supervising fellows’ endoscopy.

At noon, I round with a team of GI fellows, medical students, and housestaff rotators for 2 hours. After we see the new consults, the remainder of my afternoon is spent seeing the follow-up patients. For two afternoons throughout the week, I have outpatient endoscopy sessions. I typically conclude my day at 5 p.m.

For night coverage, I take emergency calls for my own patients, and share general call duties with the other members of my division. On average, I take calls for one weekday a month and five weekends per year.

Typically, GI hospitalists only cover inpatients during the daytime. All nights and weekends are covered by partners and nonemergent overnight consults are saved until the next day. They have no office work.
 

What is the most challenging part of being a GI hospitalist?

As the perpetual “GI Consult Attending,” there is the threat of burnout when confronted with a high volume of sick, complex patients. Many of the patients have multiple comorbidities and require a multidisciplinary approach. On average, we have five new consults a day and the number of active follow-up patients is 10. Nonetheless, the nature of the inpatient service makes the volume of work unpredictable. When the service is busy and the census swells, the numbers of patients requiring staffing and notes can become overwhelming.

 

Mike Powell/Thinkstock

While there is diversity in the types of consults, one repeatedly confronts common problems such as GI bleeding, food impactions, unexplained abdominal pain, diarrhea, dysphagia, nausea and vomiting, iron-deficiency anemia, abnormal liver tests, and PEG placements. Seeing the same consults over and over again can get tiresome. Fortunately, in a teaching hospital, this repetition is somewhat mitigated when one’s audience consists of new crops of enthusiastic medical students, rotating housestaff, and fellows.

Importantly, for those without an outpatient practice, one loses the opportunity to develop longitudinal relationships with patients. Additionally, one also loses the ability to provide integrated, comprehensive care for individual patients once they leave the hospital.
 

How are you paid?

My compensation is based on a base salary with an incentivized system based on my RVUs and collections. For the dedicated hospitalist for a group practice, there is typically a base salary and productivity-based income. Additionally, there should be a path to partnership. Lastly, in balancing the ledger, the diminished inpatient revenue stream is offset by the lack of overhead.

What are the benefits of a GI hospitalist system?

Our system benefits the workflow for the GI fellows. Since I have started, the GI consultation rounds start at a consistent time. During these rounds, we discuss relevant GI literature and make timely plans on all patients. Oftentimes, I am able to supervise the fellows so they can fit in a scope before the end of the workday. Ultimately, the fellows know they can find me and discuss patients throughout the day. The fellows consistently have told me that the since the implementation of the hospitalist system, there has been a dramatic difference. Collectively, they feel both their education and patient care have improved.

In terms of consult efficiency, one study demonstrated that the transition to a GI hospitalist system resulted in a mean decrease in consult to urgent esophagogastroduodenoscopy (EGD) time from approximately 24 to 14 hours.³ However, this occurred in the context of a lower inpatient consult volume and only covered 2 months. Furthermore, the time from admission to EGD did not change. Nonetheless, further studies are needed to examine the impact of this model shift.

In terms of a financial benefit, at our institution the total gross inpatient charges increased more than $850,000 for the year. This was largely attributable to the 79% increase in the gross charges from follow-up notes.

For group practices, the hospitalist system makes more efficient use of physician’s time. Physicians can either focus on outpatients or inpatients without worrying about going between the office, ambulatory surgical center, and the hospital. In general, inpatients require a disproportionate amount of time relative to the revenue collected. Furthermore, by eliminating the need for group physicians to go to the hospital, they can carve out 1-2 hours of office time to increase billing.

When there is one point-person whom handles all inpatient GI, communication is facilitated among primary teams and other services. The GI hospitalist develops working relationships with surgeons, radiologists, anesthesiologists, intensivists, etc. Teams can often just text or call me directly, instead of looking for the covering attending or going through the office phone service.
 

What are drawbacks to the GI hospitalist model?

Since there is only one gastroenterologist in the hospitalist model, if that person is not doing a good job, it affects the management of GI conditions for the entire hospital.

There is a loss of continuity-of-care. When GI patients get admitted, the gastroenterologists responsible for their care will not be the person with whom they have a long-term relationship. Furthermore, when the patient gets discharged, the primary gastroenterologists will not be fully aware of the inpatient course.

Also, when outpatient and inpatient gastroenterologists become segregated based on hospital setting, they each lose out of learning the intricacies of managing patients in a different context.
 

What do you like most about being a GI hospitalist?

The GI hospitalist position creates a great opportunity for gastroenterologists to make a remarkable, immediate impact on interesting, high acuity patients. The nature of the job also has the advantage of providing reasonable hours. This may be attractive to many whom want a better work-life balance.

Dr. Wan is assistant professor of medicine, associate program director, GI Fellowship Program, New York Presbyterian/Weill Cornell Medical Center, New York, N.Y.

References

1. Wachter R.M., Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Sep 15;375[11]:1009-11.

2. Estimating the Number and Characteristics of Hospitalist Physicians in the United States and Their Possible Workforce Implications. Analysis in Brief. Available at: https://www.aamc.org/download/300620/data/aibvol12_no3-hospitalist.pdf. Accessed May 1st, 2016.

3. Mahadev S., Lebwohl B., Ramirez I., Garcia-Carrasquillo R.J., Freedberg, D.E. Transition to a GI Hospitalist System is Associated with Expedited Upper Endoscopy. Gastroenterology. 2016;150[4]:S639-40.