Pathways to promotion: Making everyday work count towards scholarship opportunities

Academic rank is perceived as a reflection of clinical and academic achievement. Advancement requires evidence of meaningful scholarship as part of a faculty member's portfolio. The promotion process can feel particularly daunting to clinically focused hospitalists. Many remain at the instructor or assistant professor level, unsure of how to navigate the path to higher academic ranks.1, 2 Despite a paucity of traditional research training and experience, academic hospitalists are subject matter experts in several areas, including patient safety and quality improvement, clinical operations, technology implementation, piloting new protocols and adapting best practices. These unique domains offer a competitive advantage to hospitalists and can be leveraged to build their academic portfolios. In 1990, Ernest Boyer set out to better define scholarship within academics, and his taxonomy has since been widely adopted in the academic medical community.3 He proposed four pillars of scholarly activity: discovery, integration, application, and teaching. These pillars can be defined in any medical specialty including hospital medicine. Scholarship of discovery involves reporting of hypothesis-driven investigations, and for most institutions, is understood as either quantitative, qualitative, bench, translational or clinical trials, etc. Scholarship of integration focusses on synthesizing existing information across disciplines to reveal new connections and insights. Evidence-based clinical practice guidelines, systematic reviews, and clinical case reports are some examples of scholarship of integration. Scholarship of application focusses on using existing knowledge to address or improve gaps in existing patient care practices and develop real-life practical interventions. Quality improvement projects, clinical care pathways, community health initiatives and other care improvement programs will fall under scholarship of application. Finally, scholarship of teaching recognizes the importance of teaching beyond the classroom setting. Examples of this form of scholarship include development, implementation, and dissemination of educational curricula, assessment of such curricula, dissemination of innovative teaching methods at national conferences, peer-reviewed and nonpeer-reviewed publications in written, web-based or digital format. In their multifaceted role, hospitalists are hence uniquely positioned to excel in several domains of scholarship as defined by Boyer. We propose means for professional advancement by highlighting scholarship opportunities that can be leveraged by hospitalists in their daily work. Through involvement in various roles and projects, academic hospitalists can generate several forms of scholarship making their everyday work count twice or even more (Table 1). Hospital outcomes Patient experience improvements Patient Safety: Safety event reporting, diagnostic errors Poster Presentations Grand rounds Morbidity & Mortality conferences Peer reviewer & judging opportunities for scholarly submissions Regional & national level From senior faculty & prominent leaders Hospitalists care for a variety of hospitalized patients with atypical clinical presentations of common diseases or typical presentations of rare diseases and syndromes. These scenarios offer for dissemination opportunities in the form of abstracts, oral presentations, workshops and manuscript writing pertaining to these clinical vignettes.4, 5 Clinical management dilemmas are common in practice, at times due to paucity of evidence, or guidelines.6, 7 Such dilemmas can sometimes serve as the impetus for systemic reviews and meta-analyses and hypotheses for future clinical studies resulting in scholarship.8 Hospitalists are key members at the execution of healthcare delivery, collaborating with colleagues from different medical specialties and interprofessional disciplines including nursing, paraclinical staff, hospital leadership, health system administration, as well as patient and community representatives.9-11 These collaborations can result in valuable lessons that can also be shared as a scholarship of application. Some of the examples include development of evidence-based clinical order set or clinical pathways, disease-specific, interdisciplinary care management plans, comanagement protocols with medical and surgical subspecialty services, clinical decision support tools or usability testing in the electronic health records, transitions of care and nurse-to-physician communication standards to name a few.12-14 Apart from clinical challenges, hospitalists may encounter social and demographic challenges for their patients at their institutions or organizations. Developing quality improvement projects to address these challenges are great opportunities to improve patient care and generate scholarship.15 Quality improvement projects can span over multiple areas involving implementation of services such as a streamlined process for a quick access to language interpreter service line via digital, telephonic or in-person modality, structured process addressing goals of care for patients within a specified period after admission, best practice alerts, and electronic prompts or nudges to improve patient outcomes. Besides the venues already stated, local health improvement events like a health system-wide quality Improvement Day, annual national patient safety week and similar platforms also offer additional opportunities for dissemination and scholarship.16-18 As most of the hospitalists review literature regularly, this professional activity offers another opportunity. Such work can be captured in the form of review articles for institutional handbooks, guides or journals, point-of-care educational resources and clinical decision support tools, chapters in reputed textbooks and written educational platforms. (e.g., In The Literature Review in The Hospitalist, a monthly news magazine of the Society of Hospital Medicine [SHM], American Collge of Physicians [ACP] Journal Club etc). In addition to the commonly known, and already discussed forms of dissemination of traditional and nontraditional scholarship (written and oral), hospitalist expertise can also result in journal editorials, Op-Ed pieces, social media posts, and newsletters within one's own or national organizations such as The Hospitalist from the Society of Hospital Medicine, and IM Matters with the ACP etc. Within electronic media, there are additional opportunities for blog writing in physicians and patient-accessed websites. (e.g., Doximity, Medscape, WebMD, Medpage Today, etc.). Many academic hospitalists serve in educational roles within their training program such as residency or fellowship program director, associate program director and other leadership roles (such as longitudinal curriculum directors, site director, elective director, etc.). Such roles involve a wide range of educational program development, including curricular teaching methods for example, simulation techniques and gamification, development or implementation of assessment methods, such as validated tools, and quizzes amongst others.19, 20 While a growing number of institutions are beginning to curate a list of faculty resources of journals and other venues for medical education publications, platforms, such as MedEdPORTAL, Journal of General Internal Medicine, Society of General Internal Medicine (SGIM) Forum, Journal of Graduate Medical Education, AAIM (Alliance for Academic Internal Medicine) Perspective Section of the American Journal of Medicine frequently offer suitable scholarship homes in the realm of medical education. Hospitalists are often at the forefront of these programs and could capitalize on the opportunity to disseminate their curricula through scholarly means.19, 21, 22 Dissemination can occur in traditional formats such as peer-reviewed publications, abstracts, posters, and workshops at professional meetings and online forums, where the number of citations captured through H-index, visits and downloads can be tracked to measure success. The Society of Hospital medicine has several educational content areas online that are contributed by hospitalists, for example, the Brief Talks for Medical Educators series by the Society of Hospital Medicine or the GIM Learn series for the Society of General Internal Medicine are additional options to consider. Outside of leading hospitalist and general internal medicine societies and their publications, hospitalist work that is shared with interprofessional colleagues can also be disseminated within venues of several other subspecialty and nonphysician healthcare societies and publications.23, 24 Institute of Health Care Improvements (IHI) annual conferences, for example, IHI Forum and IHI Safety Congress, both offer additional venues for presentation of interprofessional work. Lastly, professional advancement through completion of certain certification and training within or outside one's institution may also qualify as an expertise and count towards the promotion process. A non-exhaustive list of examples include the Society of Hospital Medicine and the Institute for Healthcare Improvement which offer online training modules in quality and patient safety (SHM–QSEA, Academic Hospitalist Academy; IHI Open School; SGIM–MedEd Scholar), and the Medical Education Research, Innovation, Teaching, and Scholarship Program from the University of Chicago are some examples of additional training programs. The Academic Pediatric Association also offers a 2-year Education and Quality Scholars training program. Nationally renowned programs in quality improvement are offered through Intermountain Health's Advanced Training Program and Cincinnati Children's Intermediate Improvement Science Series and Advanced Improvement Methods. Several institutions offer online live or asynchronous master's programs in medical education. Each of these training programs can help hospitalists expand their skill sets while providing opportunities for additional scholarship. Hospitalists are key stakeholders in the inpatient setting and contribute to hospital operations in many ways. They often chair or cochair hospital committees and quality improvement initiatives. Some committees are disease-specific, aiming for better care delivery, while others focus on improving health system metrics, such as patient flow and patient satisfaction.25 Successful initiatives, especially if sustainable positive impact is demonstrated in patient care or health system performance, are ideal examples of activities worthy of dissemination. The Journal of Hospital Medicine's (JHM) Next Steps column provides a forum for reporting either policy changes or innovations in practice. JHM's Innovations Corner article type is intended to share innovative initiatives, whether successful or not, that yield generalizable insights.26, 27 Hospitalists should also explore other venues of dissemination, such as unindexed (not indexed in PubMed yet, could be peer-reviewed), or non-peer-reviewed (such as essays, podcasts, etc.) that align with their project and not just be limited to physician-only forums, such as interprofessional conferences like the annual IHI Forum and IHI Safety Congress. The interprofessional nature of hospitalists' work potentiates a larger reach and may create a wider array of viable scholarship venues by co-presenting and co-authoring with the interprofessional colleagues who make this type of teamwork possible. The nature of this collaborative work also opens an opportunity to mentor an interprofessional staff towards scholarship.28 Networking with peers provides opportunities for professional development and collaborative work which can result in scholarship opportunities.14, 29 Participating in local, regional, or national interest groups or events can be a valuable early step to develop a healthy peer-network. Such collaborative relationship, for example between the Academic Hospitalist Commission of the SGIM and Society of Hospital Medicine (SHM) has resulted in publications on topics of mutual interest.30 Involvement in professional societies also offers opportunities to find a diverse range of mentors beyond one's own institution who can provide additional valuable guidance in meaningful scholarly outputs from everyday hospitalist work. Many hospitalists are involved in advocacy work for the patients they serve. Such work, for example, advocating for improved care coordination and access for homeless patients, improved patient to physician communication through development of patient friendly discharge instructions for inpatients, offer another opportunity for dissemination.15 While it varies across institutions, some institutions have a portfolio to define “advocacy scholarship” to support faculty engaged in such efforts.31, 32 Some examples of published advocacy portfolio contain specific criteria for example, documenting primary area/areas of concern, advocacy engagements, dissemination, outreach, teaching, mentoring, leadership, administration, scholarly products, and advanced training in advocacy skills to name a few. Social media offers a platform not only for socializing but also for learning and information dissemination. Summarizing and sharing content for a wider audience, both medical and nonmedical, has the potential to impact our community and offer another venue for domains of scholarship as defined by Boyer.33 In addition, the creation of medical threads, infographics and tutorials online can convert complex information into bite-sized and reader-friendly content and may also be considered a scholarly product at some academic institutions.34-36 In summary, developing and implementing an action plan that incorporates academic hospitalists professional interests and tailored to their institutional-specific promotion criteria, can provide a road map towards academic advancement.37, 38 Manuscript writing is an iterative process, and it needs practice, perseverance, and choosing the right approach for the thoughts or ideas.39 In addition, seeking diverse range of mentors and active participation in professional societies can further aid in exploring scholarship opportunities. Academic hospitalists may consider joining or creating writing accountability groups within their organization or contributing to writing challenges offered nationally via SHM to support and inspire each other.40, 41 It is important for academic hospitalists to recognize that there are several current and evolving venues which offer opportunities to make their everyday work count toward scholarship. The authors declare no conflicts of interest.