The field of hospital medicine (HM) is rapidly expanding in the areas of clinical medicine, administration, and quality improvement (QI).1 Emerging with this growth is a gap in the traditional internal medicine (IM) training and skills needed to be effective in HM.1,2 These skills include clinical and nonclinical aptitudes, such as process improvement, health care economics, and leadership.1-3 However, resident education on these topics must compete with other required curricular content in IM residency training.2,4 Few IM residencies offer focused HM training that emphasizes key components of successful HM careers.3,5
Within the past decade, designated HM tracks within IM residency programs have been proposed as a potential solution. Initially, calls for such tracks focused on gaps in the clinical competencies required of hospitalists.1 Tracks have since evolved to also include skills required to drive high-value care, process improvement, and scholarship. Designated HM tracks address these areas through greater breadth of curricula, additional time for reflection, participation in group projects, and active application to clinical care.4 We conducted a study to identify themes that could inform the ongoing evolution of dedicated HM tracks.
Programs were initially identified through communication among professional networks. The phrases hospital medicine residency track and internal medicine residency hospitalist track were used in broader Google searches, as there is no database of such tracks. Searches were performed quarterly during the 2015–2016 academic year. The top 20 hits were manually filtered to identify tracks affiliated with major academic centers. IM residency program websites provided basic information for programs with tracks. We excluded tracks focused entirely on QI6 because, though a crucial part of HM, QI training alone is probably insufficient for preparing residents for success as hospitalists on residency completion. Similarly, IM residencies with stand-alone HM clinical rotations without longitudinal HM curricula were excluded.
Semistructured interviews with track directors were conducted by e-mail or telephone for all tracks except one, the details of which are published.7 We tabulated data and reviewed qualitative information to identify themes among the different tracks. As this study did not involve human participants, Institutional Review Board approval was not needed.
We identified 11 HM residency training programs at major academic centers across the United States: Cleveland Clinic, Stanford University, Tulane University, University of California Davis, University of California Irvine, University of Colorado, University of Kentucky, University of Minnesota, University of New Mexico, Virginia Commonwealth University, and Wake Forest University (Table 1). We reviewed the websites of about 10 other programs, but none suggested existence of a track. Additional programs contacted reported no current track.
Track Participants and Structure
HM tracks mainly target third-year residents (Table 1). Some extend into the second year of residency, and 4 have opportunities for intern involvement, including a separate match number at Colorado. Tracks accept up to 12 residents per class. Two programs, at Colorado and Virginia, are part of IM programs in which all residents belong to a track (eg, HM, primary care, research).
HM track structures vary widely and are heavily influenced by the content delivery platforms of their IM residency programs. Several HM track directors emphasized the importance of fitting into existing educational frameworks to ensure access to residents and to minimize the burden of participation. Four programs deliver the bulk of their nonclinical content in dedicated blocks; 6 others use brief recurring sessions to deliver smaller aliquots longitudinally (Table 1). The number of protected hours for content delivery ranges from 10 to more than 40 annually. All tracks use multiple content delivery modes, including didactic sessions and journal clubs. Four tracks employ panel discussions to explore career options within HM. Several also use online platforms, including discussions, readings, and modules.
The vast majority of curricula prominently feature experiential QI project involvement (Table 2). These mentored longitudinal projects allow applied delivery of content, such as QI methods and management skills. Four tracks use material from the Institute for Healthcare Improvement.8 Several also offer dedicated QI rotations that immerse residents in ongoing QI efforts.
Institutional partnerships support these initiatives at several sites. The Minnesota track is a joint venture of the university and Regions Hospital, a nonprofit community hospital. The Virginia track positions HM residents to lead university-wide interdisciplinary QI teams. For project support, the Colorado and Kentucky tracks partner with local QI resources—the Institute for Healthcare Quality, Safety, and Efficiency at Colorado and the Office of Value and Innovation in Healthcare Delivery at Kentucky.
Health Care Economics and Value
Many programs leverage the rapidly growing emphasis on health care “value” as an opportunity for synergy between IM programs and HM tracks. Examples include involving residents in efforts to improve documentation or didactic instruction on topics such as health care finance. The New Mexico and Wake Forest tracks offer elective rotations on health care economics. Several track directors mentioned successfully expanding curricula on health care value from the HM track into IM residency programs at large, providing a measurable service to the residency programs while ensuring content delivery and freeing up additional time for track activities.
Scholarship and Career Development
Most programs provide targeted career development for residents. Six tracks provide sessions on job procurement skills, such as curriculum vitae preparation and interviewing (Table 2). Many also provide content on venues for disseminating scholarly activity. The Colorado, Kentucky, New Mexico, and Tulane programs feature content on abstract and poster creation. Leadership development is addressed in several tracks through dedicated track activities or participation in discrete, outside-track events. Specifically, Colorado offers a leadership track for residents interested in hospital administration, Cleveland has a leadership journal club, Wake Forest enrolls HM residents in leadership training available through the university, and Minnesota sends residents to the Society of Hospital Medicine’s Leadership Academy (Table 2).
Almost all tracks include a clinical rotation, typically pairing residents directly with hospitalist attendings to encourage autonomy and mentorship. Several also offer elective rotations in various disciplines within HM (Table 2). The Kentucky and Virginia tracks incorporate working with advanced practice providers into their practicums. The Cleveland, Minnesota, Tulane, and Virginia tracks offer HM rotations in community hospitals or postacute settings.
HM rotations also pair clinical experiences with didactic education on relevant topics (eg, billing and coding). The Cleveland, Minnesota, and Virginia tracks developed clinical rotations reflecting the common 7-on and 7-off schedule with nonclinical obligations, such as seminars linking specific content to clinical experiences, during nonclinical time.
Our investigation into the current state of HM training found that HM track curricula focus largely on QI, health care economics, and professional development. This focus likely developed in response to hospitalists’ increasing engagement in related endeavors. HM tracks have dynamic and variable structures, reflecting an evolving field and the need to fit into existing IM residency program structures. Similarly, the content covered in HM tracks is tightly linked to perceived opportunities within IM residency curricula. The heterogeneity of content suggests the breadth and ambiguity of necessary competencies for aspiring hospitalists. One of the 11 tracks has not had any residents enroll within the past few years—a testament to the continued effort necessary to sustain such tracks, including curricular updates and recruiting. Conversely, many programs now share track content with the larger IM residency program, suggesting HM tracks may be near the forefront of medical education in some areas.
Our study had several limitations. As we are unaware of any databases of HM tracks, we discussed tracks with professional contacts, performed Internet searches, and reviewed IM residency program websites. Our search, however, was not exhaustive; despite our best efforts, we may have missed or mischaracterized some track offerings. Nevertheless, we think that our analysis represents the first thorough compilation of HM tracks and that it will be useful to institutions seeking to create or enhance HM-specific training.
As the field continues to evolve, we are optimistic about the future of HM training. We suspect that HM residency training tracks will continue to expand. More work is needed so these tracks can adjust to the changing HM and IM residency program landscapes and supply well-trained physicians for the HM workforce.
The authors thank track directors Alpesh Amin, David Gugliotti, Rick Hilger, Karnjit Johl, Nasir Majeed, Georgia McIntosh, Charles Pizanis, and Jeff Wiese for making this study possible.
Nothing to report.