Hospital medicine is the fastest growing medical specialty in the US.1,2Hospitalists are advanced practice providers (APPs)—NPs and physician assistants—and physicians who manage patients hospitalized with general medical conditions. Hospitalist programs are an integral part of hospital practice and are associated with improved efficiency, reduced length of stay, and increased patient satisfaction compared with nonhospitalist programs.3,4 Despite the increased presence of APP and physician hospitalists, many hospitalists are not actively involved in research, the reasons for which are not completely understood.5,6 It is also unknown if APPs and physicians differ in their perspectives and barriers to participate in research.
The authors conducted a survey of APP and physician hospitalists at an academic healthcare system, which includes more than 15 hospitals across four US states in the Midwest, Southeast, and Southwest to better understand how different educational backgrounds and preparation for hospital medicine are associated with profession-specific barriers to conduct research.
In the mid-1990s, the term hospitalist was used to define specialists in internal medicine who managed the care of hospitalized patients.7 Since then, the number of hospitalists has increased from fewer than 1,000 (in 1996) to more than 44,000 (in 2014).8 Early in the development of hospitalist programs, most hospitalists were general medicine specialists with formal training in family medicine, internal medicine, or pediatrics.1 Over the last 20 years, the breadth and depth of hospitalist responsibilities have expanded to include comanagement of patients on surgical services (for example, vascular surgery) and specialty services (for example, cardiology, gastroenterology), as well as functions beyond patient care including education and research.5,9-17 Most hospitalists have completed 3 to 4 years of residency with a subset having completed a fellowship in hospital medicine; a minority of programs have a research fellowship program for formal research training.5,18
Over the last 20 years, hospitalist programs have also transformed with the incorporation of APPs in the practice. APPs are NPs and physician assistants, who are independently licensed providers with varying levels of autonomy to work with physicians and provide care to hospitalized patients.19,20 Similar to the growth of physician hospitalists, the APP workforce in the US has increased and now includes over 290,000 NPs and 140,000 physician assistants, many of whom are involved in hospital practice.19,20 APPs have completed a master's or doctoral degree program with clinical rotations, with a subset having completed a fellowship in hospital medicine; many do not have formal research training.19,20
Hospitalist programs are a vital dimension of hospital practice, and over 80% of hospitals with more than 200 beds rely on hospitalists to manage patients.8 Despite the growth and impact of hospitalist programs, hospitalist participation in research has trailed their involvement in patient care. A recent survey of hospitalist programs showed that only 12% of faculty members had intramurally or extramurally funded research (n = 192/1,586), and of those individuals, 58% had less than a quarter of their time protected for research (n = 112/192); 61% of hospitalist programs had less than $500,000 in funding (n = 17/28).5 As the hospitalist workforce increases nationwide, equipping hospitalists with research skills may provide a sustainable mechanism to generate knowledge and improve outcomes for hospitalized patients.
Studies examining barriers for participation in research have largely focused on physicians, who identified factors including the lack of mentorship, time, and institutional support.5,18,21-24 To the authors' knowledge, sparse information exists on barriers perceived by APPs, and no reports compare the perspectives and research skills of APP and physician hospitalists. To address these knowledge gaps, the authors conducted a descriptive research survey of APP and physician hospitalists to guide the development of research skills needed to improve patient outcomes, hospital practice, and research productivity.
This study was approved by the Institutional Review Board at Mayo Clinic, Rochester (IRB 19-001729).
Participants. Participants were hospitalists at Mayo Clinic, comprised of APPs and physicians who manage adults hospitalized with general medical conditions. Participants included full-time and part-time hospitalists, and excluded trainees (students, residents, and fellows) as well as hospitalists in other specialties.
Survey sites. Hospitalists at Mayo Clinic in Rochester, Minn.; Jacksonville, Fla.; Scottsdale, Ariz.; and Mayo Clinic Health Systems in Wisconsin (Barron, Bloomer, Eau Claire, La Crosse, Menomonie, and Osseo) and Minnesota (Albert Lea, Austin, Cannon Falls, Fairmont, Lake City, Mankato, Owatonna, and Red Wing) were emailed a survey assessing their perspectives on research, barriers for participation in research, and research skills they would like to acquire. The survey sites included more than 15 academic and community hospitals within a single academic healthcare system. The approximate number of hospital beds at each site was 260 (Scottsdale, Ariz.), 300 (Jacksonville, Fla.), 1,000 (Mayo Clinic Health Systems), and 2,050 (Rochester, Minn.). Survey respondents were dichotomized by profession (APPs and physicians).
Survey development and administration. The authors developed the 24-question survey instrument based on knowledge gaps identified in the literature and expert input from all survey sites. Survey domains included demographic information, barriers for participation in research, and current and aspirational research skills, and required approximately 5 to 10 minutes to complete. The survey instrument was developed and administered using Research Electronic Data Capture (REDCap).25,26 REDCap is a secure, web-based platform to support data capture for research studies, providing an intuitive interface for validated data entry audit trails for tracking data manipulation and export procedures, automated export procedures for seamless data downloads to common statistical packages, and procedures for importing data from external sources.25,26 EndNote is a commercial software package to manage references and bibliographies for articles.27 Each participant received a unique link to the survey with up to two reminders over the 6-week survey period from March 2019 through April 2019.
Data analysis. Responses on a 5-point Likert scale were condensed into three categories: disagree (strongly disagree or disagree), neutral, and agree (agree or strongly agree). Responses between APPs and physicians were compared using Fisher's exact test with statistical significance at P < .05. Data were analyzed using SAS University Edition (SAS Institute Inc., Cary, N.C.).
Demographics of APPs and physicians. Among 275 hospitalists (87 APPs and 188 physicians), the response rate was 54% (n = 148/275); among APPs, the rate was 57% (n = 50/87) and among physicians, 52% (n = 98/188). The proportion of female participants was higher among APPs compared with physicians (78% versus 39%) (P < .0001). Compared with 6% of APPs, 42% of physicians were at or above the rank of assistant professor, while 43% of APPs and 34% of physicians had no academic rank (P < .0001). APPs and physicians similarly valued receiving an academic rank/promotion (agree: 46% APPs versus 67% physicians) (P = .08), were interested in participating in research (agree: 68% APPs versus 82% physicians) (P = .07), and were willing to commit time for research. (See Characteristics of responding hospitalists, categorized by profession.)
Current research skills of APPs and physicians. Most APPs and physicians reported having skills to conduct a literature search (agree: 85% to 88%) and critically review the literature (agree: 58% to 72%), but not to use REDCap (agree: 31% to 33%) (all, P > .05). (See Current research skills of hospitalists, categorized by profession.) APPs and physicians differed in their current skill to use EndNote (agree: 8% APPs versus 32% physicians) (P = .003), submit an IRB application (agree: 16% APPs versus 48% physicians) (P = .0006), write manuscripts (agree: 27% APPs versus 55% physicians) (P = .004), and write grants (agree: 0% APPs versus 11% physicians) (P = .03).
Barriers for research among APPs and physicians. The proportion of hospitalists with ≤3 peer-reviewed publications was 98% (n = 47/50) for APPs and 48% (n = 45/98) for physicians (P < .0001). Among these hospitalists, 40% of APPs and 66% of physicians agreed that lack of mentorship was a barrier for participation in research (P = .02). Other barriers for research participation were generally similar between APPs and physicians and included lack of time for research (agree: 68% to 79%), lack of funding (agree: 34% to 43%), and lack of research skills (agree: 43% to 59%) (all, P > .05). (See Barriers for research among hospitalists with research barriers [≤3 peer-reviewed publications], categorized by profession.) Most APPs and physicians reported pursuing other interests, which was a barrier for participating in research (agree: 57% to 63%) (P = .14).
Research skills that APPs and physicians would like to acquire. Despite having research skills, most APPs and physicians were interested in acquiring additional skills for research. APPs and physicians reported generally similar interest to acquire skills to conduct a literature search (agree: 58% to 64%), critically review the literature (agree: 61% to 70%), use REDCap (agree: 64% to 72%), use EndNote (agree: 64% to 73%), learn the IRB process (agree: 57% to 68%), write manuscripts (agree: 79% to 82%), and write grants (agree: 52% to 61%) (all, P > .05). (See Research skills that hospitalists would like to acquire, categorized by profession.)
In this study, APP and physician hospitalists similarly valued academic rank/promotion, were interested in participating in research, and were willing to commit time for research. Despite these similarities, more physicians compared with APPs were at or above the rank of assistant professor. APPs and physicians identified barriers for research including lack of time, research skills, and funding. Compared with physicians, fewer APPs reported having research skills to submit an IRB application, write manuscripts, and write grants. However, both groups were similarly interested in acquiring additional skills for research. To the authors' knowledge, this is the first study that compares the research perspectives and skills of APP and physician hospitalists and identifies system-level as well as profession-specific opportunities to improve skills and research productivity.
The research barriers experienced by APPs are not well understood as most previous studies focused on barriers reported by physicians.6,22,24 These studies showed that the lack of mentorship, time, and institutional support to expand to nonclinical activities have been key barriers for physician hospitalists to participate in research, similar to observations in this study.6,22,24 A recent survey of APPs from various specialties not specific to hospital internal medicine at the study institution showed that the majority of APPs experienced barriers for academic promotion including lack of time and lack of understanding the promotions process.28 Mentorship, opportunities for research productivity, and securing academic rank and promotion may also be influenced by gender. Previous studies showed that women are less likely to receive mentorship and academic promotion, compared with their male counterparts.29-32 In this study, 78% of APPs and 39% of physicians were women, and further research is required to determine how and why gender influences mentorship and academic promotion.
In this study, APP and physician responses indicated similar research skills and differences as well. The differences between APPs and physicians may reflect the primary responsibility of APPs to engage in patient care and a relatively lower emphasis on research during their training and practice. Although physician hospitalists also dedicate most of their time to patient care, they likely acquire more exposure and opportunities to contribute to manuscripts and grants through research experiences in medical school, residency, and fellowship. Both APPs and physicians were interested in improving skills for research, which could lead to increased research productivity and academic promotion.
Survey results provide a framework to develop programs that cultivate skills for research. For instance, educational programs could be developed in collaboration with research librarians (for EndNote and REDCap), researchers with an extensive publication record (to write manuscripts), institutional grants offices and researchers with a track record of securing intramural and extramural funding (to write grants), to provide tailored sessions for APPs and physicians. Such educational programs may be most effective when linked to a research idea or proposal under development. Institutions have created programs such as the SCHOLAR (SuCcessful HOspitaLists in Academics and Research) project to support academic growth and productivity.33 To reduce barriers to academic promotion among APPs, a program (combination of educational sessions, tutorials, and mentorship) was developed to increase support for APPs and foster academic productivity.34 Such efforts could help improve academic success, mitigate provider burnout, and reduce faculty attrition.35,36
This study has limitations. The response rate was 54%, which was higher than that of other surveys, but may not reflect the perspectives of nonresponders.5,37 These results are from more than 15 hospitals within a single academic healthcare system and may not reflect perspectives at other institutions. The survey included hospitalists with night shifts totaling more than 50% of all shifts (20% of APPs and 10% of physicians), which may affect attitude toward research. However, this study has several strengths as it compared perspectives among different hospitalists (APPs and physicians), and identified actionable barriers and modifiable skills that can guide systemwide initiatives to improve academic productivity and promotion. This study incorporates providers from more than 15 hospitals in four US states, including academic and community hospitals.
In this study, APPs and physician hospitalists were more similar than different with respect to research barriers, skills, and aspirations, which highlight systemwide factors that may affect academic productivity, rank, and promotion. At present, hospitalists are primarily expected to focus on patient care, education of learners, administrative work for hospital practice, and quality improvement initiatives for hospital practice.6,7,18,24 Consequently, hospitalist recruitment often focuses on the needs of the hospital practice, and less so on academic potential. Many hospitalists enter hospital practice without research experience or skills, and find it challenging to acquire them in the context of full-time hospital practice, and lack of mentorship, time, and funding. Most institutions have minimal financial support (for example, grants, career development awards) for hospitalists to protect time, build skills, and generate evidence for improved hospital practice.5 Nationwide, APPs are an integral part of hospital practice, and participating in research to impact healthcare is enshrined in the vision of their national organizations.19,20,28 As the APP and physician hospitalist workforce increases nationwide, equipping them with research skills may provide a sustainable mechanism to yield new knowledge, enhance the efficiency of hospital practice, and improve outcomes for patients.
In summary, APPs and physicians in hospital internal medicine are more similar than different in their perspectives and barriers for research. These results provide a framework to develop programs for hospitalists to acquire research skills and increase their research productivity. Future studies should evaluate the impact of such programs on academic rank and promotion, hospitalist burnout, and hospitalist attrition.
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