A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years

Hospital medicine is a rapidly growing field, and among internal medicine (IM) sub-specialties, second in size only to general IM.^1,2  Specialties outside of IM are also incorporating hospital-based providers into their care delivery models, including obstetrics and gynecology, surgery, IM subspecialties, neurology, otolaryngology, and pediatrics.^3-8  The hospitalist model has evolved to address the need to deliver high-value care for an inpatient population with increasing acuity and complexity while also considering quality of life factors with physician coverage models.^3,5,6  Hospitalists develop a mastery of inpatient clinical care and provide increased on-site availability in the hospital setting, while also enhancing delivery of high-value care.^1,9 

For IM hospitalists, a significant portion of the clinical work is in neurology, consultative medicine, surgical co-management, and palliative care, areas historically underemphasized in internal medicine residency programs (IMRPs).^10,11  There are also gaps in traditional IM training in nonclinical areas important for hospital medicine clinicians: health care economics, patient safety and quality improvement (QI), practice management, continuums of care, leadership skills, and communication.¹² 

To meet these needs, some IMRPs have developed dedicated hospital medicine curricula and clinical training.^13-16  Most incorporate curricular content on career development and core competencies in hospital medicine, including hospital-based clinical experiences, QI, and health care economics.^13,15,17  At the same time, hospital medicine fellowships were developed to meet the needs of graduating residents entering hospital medicine who did not have specific residency training.¹⁸  To date, graduate outcomes or program evaluation for IM-based fellowship programs or residency tracks have not been described, and the optimal training to prepare physicians for the current landscape of hospital medicine is unknown, including whether it should be a residency track, a fellowship program, or both.

Training paths and board certification also currently differ across hospital-based specialties. Pediatrics created dedicated fellowships, and completion of a pediatric hospital medicine fellowship is now required to be board-eligible for pediatric hospital medicine.¹⁹  The American Board of Internal Medicine (ABIM) has a focused practice in hospital medicine certification, but it is considered a variation of IM certification, not a subspecialty.²⁰  Similar to IM, surgery and obstetrics and gynecology have created acute care or hospital-based fellowships that are not accredited by the Accreditation Council for Graduate Medical Education.^18,21,22 

We aim to describe the first and longest running Hospitalist Training Track (HTT) embedded within an IMRP and to track evaluation data, including graduate feedback, graduate practice patterns, and track feasibility.

The University of Colorado HTT is embedded within the IMRP with the first graduating class in 2005 and a total of 124 graduates from 2005 to 2019. Currently, medical students can match directly into the track through the National Resident Matching Program, or University of Colorado IM residents can apply to transfer to the track via a letter of interest after their career interests solidify.

The HTT is evaluated and refined yearly; current track components are detailed in the Figure. The clinical curriculum now consists of 20 weeks of inpatient rotations (Figure). Trainees not in the hospitalist track may do outpatient-based oncology/bone marrow transplant, neurology, and geriatrics, and they can take the Hospitalist Preceptorship and Consults/Perioperative electives if space is available. An additional 24 half-days are dedicated to systems of care exploration. Residents not in the track spend those half-days in a subspecialty clinic or additional time in their primary care continuity clinic. Each resident participates in a longitudinal team-based QI project focused on initiatives that align with resident interest and health care system priorities. Trainees not in the track continue to participate in clinic-based QI projects.

IMRP career development didactics include preparing a curriculum vitae and cover letter and participation in mock interviews; residents in the hospitalist track also attend a hospitalist career panel and a session reviewing the application process and contract negotiation. All residents in the IM program are assigned a faculty coach and connect with a scholarship mentor. Residents on the hospitalist track receive additional mentoring from a faculty QI coach, a faculty mentor aligned with future career interests, monthly journal clubs combined with faculty discussion of career path, and program director mentorship. The goals of mentorship are to expose residents to the variety of career trajectories in hospital medicine, enhance their experience and skill development with project work so they can more readily take on projects as junior faculty, and support them through the job application process.

For all 124 graduates from 2005 to 2019, we determined their current practice location utilizing personal connections, hospital medicine group websites, and LinkedIn. We obtained ABIM Internal Medicine Initial Certification Examination pass rates for these graduates and compared these to the overall IMRP pass rates. We had contact information for 112 of 124 graduates with prior consent received to contact them and we sent a 14-question survey (provided as online supplementary data) electronically via REDCap 9.5.28 (Vanderbilt University). Graduates received an email from current program leadership requesting voluntary participation followed by 2 reminder emails between January and May 2020.

The survey was developed based on a review of prior alumni survey questions and input from program leadership. Survey domains included (1) Current practice; (2) Graduates' roles and projects; and (3) HTT assessment. We pilot-tested the survey using cognitive interviewing techniques among 3 currently practicing physicians chosen to obtain diverse perspectives from University of Colorado IMRP graduates and non-University of Colorado graduates in addition to community and academic providers.

We used descriptive statistics to categorize graduates' roles and current practices using Microsoft Excel 2007. Thematic content analysis was used to evaluate free text responses for leadership roles and graduate assessment of the program, which was completed by 3 coders (J.L., E.G., M.J.D.). For each free response question, we first independently reviewed the responses and identified general categories of the responses. Consensus was developed for each general category and responses were independently reviewed and coded in at least one category; some responses fit in multiple categories. A fourth reviewer (T.A.) independently examined the uncoded data and reviewed the categories derived by the other coders and helped to resolve any coding discrepancies. We tabulated the frequency of responses by category using Excel.

The Colorado Institutional Review Board deemed this study exempt as program evaluation and non–human subjects research (COMIRB 19-2421).

Of the 124 graduates from 2005 to 2019, 97 (78.2%) practice hospital medicine. Among hospitalists, 45 (46.4%) are academic hospitalists (defined as full-time faculty in a medical school) and 52 (53.6%) practice in a community- or university-affiliated setting. The most common subspecialties graduates completed fellowships in are pulmonary critical care (9 of 124 graduates, 7.3%), cardiology (6, 4.8%), and gastroenterology (3, 2.4%). The ABIM Internal Medicine Initial Certification Examination pass rate for HTT graduates between 2005 and 2019 was 96.7% (120 of 124); the pass rate for all University of Colorado IMRP graduates in this time frame was 95.5% (687 of 719).

The survey was sent to the 112 graduates for whom we had a current email address. Out of 124 graduates, 62 completed the survey (50%); their practice settings are described in Table 1. The majority of respondents (46, 74.2%) graduated between 2013 and 2019, but there were respondents from every graduating year except 2005. Graduates have participated in a variety of projects and roles during their careers, and most respondents (50, 80.6%) have held leadership roles (Table 1).

We asked graduates to identify the most valuable components of the HTT for their professional development (Table 2). Three main areas were identified from their free text responses: nonclinical teaching (42 respondents, 67.7%), clinical experiences (39, 62.9%), and career development/mentorship (21, 33.9%); Table 2 details the specific aspects identified. The free text responses describing graduates' recommendations for additional content were organized into 4 areas: nonclinical teaching, clinical experiences, career development, and transition to independent practice (Table 2).

The resources required for successful integration of a hospital medicine track are outlined in Table 3.

To our knowledge, this represents the first report of graduate outcomes and program evaluation from a HTT for IM residents and the first report from any hospitalist training program outside of pediatric hospital medicine fellowships.²³  By surveying graduates we identified the essential components of the current training track and uncovered important aspects of practicing hospitalist roles that should be considered in a comprehensive HTT or program. Graduates valued the clinical experiences, particularly the hospitalist preceptorship and perioperative electives, nonclinical training, and structured mentorship provided by the track. With the unique perspective of at least 1 year of independent practice after foundational hospital medicine training, graduates had multiple suggestions regarding what to include to better prepare residents for their future careers. The responses also reflect the evolution of hospital medicine, including the incorporation of point-of-care ultrasound and expanded hospitalist roles in systems of care.^2,24,25 

The majority of graduates (97 of 124, 78.2%) currently practice in hospital medicine, in line with published data of graduates from other specific clinical tracks within IM.^26-28  Additionally, a significant proportion of respondents have held leadership roles (50, 80.6%) and produced scholarship (29, 46.8%), similar to a report of graduates from a pediatric hospital medicine fellowship.²³  We believe this reflects the mentorship, leadership training, and project experience in the track.

Leadership education was perceived to be valuable by graduates but was nonetheless recognized as an area for further enhancement. Current programs should consider evaluating and refining their leadership training offerings, and new programs should construct this as a programmatic cornerstone. Most hospitalist training incorporates participation in QI work and exposure to health care economics.¹³  Our results support this approach as many of our graduates play a key role in QI initiatives and hold leadership positions including division and group leadership that require budgetary oversight and a basic understanding of finances.^29,30  However, very few hospitalist training programs include exposure to hospital operations, such as patient flow, census management, and triaging, which could be better represented in future training offerings as a significant portion of respondents hold clinical leadership roles or reported involvement in clinical operations projects.

There are a few important limitations to this study. First, the survey response rate was 50%. However, this is in line with other medical education graduate survey response rates,^26,31  and respondents closely matched our overall program graduates in terms of proportion of hospitalists and practice settings. Second, the respondents were skewed toward more recent graduates from the last 7 years, likely due to more accurate contact information and closer ties to the program, introducing the likelihood of self-selection bias. Although feedback from this time frame is more applicable for the evaluation of the current track, the higher proportion of recent graduates also reduces the ability to draw conclusions about long-term career outcomes after graduation. Next, we relied on self-reported survey data for roles, projects, and scholarly output; however, given our independent knowledge of graduates we were able to identify and independently verify most leadership roles. Finally, this represents graduate outcomes and evaluation from a single program within an IMRP, limiting generalizability. Nevertheless, because this graduate population represents a diverse set of practice settings from an established HTT, we believe these findings can offer guidance to other programs constructing hospital medicine training experiences.

While this track was embedded within an IMRP, these findings are not limited to this specialty. Many other specialties have hospitalist models to support inpatient care and over half of newly graduated specialists are interested in hospital-based work in their specialty.³²  While the clinical rotations would differ, the overarching structure of the program and the nonclinical work could be utilized to similarly prepare graduates in other specialties. Future directions of study could include collaboration between specialties to examine when fellowship training should be implemented compared to tracks or programs within residency training.

A dedicated HTT embedded within an IMRP is feasible and produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles, highlighting the diverse and changing field of hospital medicine. Graduates valued tailored clinical training and skill development in leadership, quality and safety, and the business of health care to meet career needs.

The authors would like to thank Dr Darlene Tad-y for her leadership in developing this training program and Dr Geoffrey Connors for his ongoing support of the program.