Growing an HM division
Hospitalist leaders at some facilities have moved their groups out from under the umbrella of general internal medicine to launch divisions of hospital medicine, in what they see as an evolutionary step for the field.
Few people knew what a hospitalist was when Katherine Hochman, MD, MBA, became the first one at Tisch Hospital in 2004 after completing her internal medicine residency at New York University (NYU) Langone Health in New York City.
“People thought for a long time that it was like a hospice attending, and then other people sometimes thought it was like a hospitality specialist,” Dr. Hochman said. “People didn't know what a hospitalist was, so in those early days, we created a mission and vision statement for who we were. We wanted to define ourselves before others defined us.”
As director and founder of the hospitalist group, she crafted the statement with NYU Langone's Office of Development and Learning. In the very last section, which projected five to 10 years into the future, the NYU hospitalist group proclaimed, “We are now the Division of Hospital Medicine.”
“That was always my vision: that one day—and I never knew when that day would actually come—we would be our own division,” she said.
That day came on July 1, 2021, when Dr. Hochman took the helm as the inaugural director of the division of hospital medicine in the department of medicine at NYU Langone. “In one word, it is validating,” she said. “It's been a long time coming, and it's been an amazing journey.”
Dr. Hochman isn't the only hospitalist to start a hospital medicine division in recent years. Since the COVID-19 pandemic hit, hospitalist leaders around the country have moved their groups out from under the umbrella of general internal medicine (GIM) to begin new divisions—a transformation they said is significant not only for them, but for hospital medicine as a field.
Moving on up
Although creating a division had been on Dr. Hochman's mind for a long time, it was her group's response to the COVID-19 pandemic that crystallized the idea for the hospital's leadership.
“I think COVID catalyzed the views on the value of a hospitalist,” she said. “Obviously, New York in March 2020 was a very dark time, and my team really performed.”
During the early days of the pandemic, it was critical for Dr. Hochman to communicate with and connect nonhospitalist clinicians. She and other clinical leaders created a “COVID Army” of outpatient physicians to care for an entire patient population ill with COVID-19 at NYU Langone, with hospitalists serving as their guides.
Also, while Dr. Hochman was in quarantine herself for COVID-19 in March 2020, she created the NYU Family Connect initiative, in which the family of every patient got a proactive call from a health care worker who provided a medical update. “It was profiled on ‘The Today Show,’ which was fun,” she said. “This gave us a lot of exposure as to how hospitalists could pivot and use resources to help the community.”
Dr. Hochman also sent a newsletter called the COVID Daily to hundreds of staff every night. The emails provided art and inspiration to help people get through the day, as well as practical updates on topics like massive inpatient expansion, educational programs, new research, and mental health resources for frontline staff.
“It was things like that that I think made us more visible as leaders at a time of crisis, and I think that's what really kind of helped make the senior administration make the decision, ‘Hey, they really need to have their own voice, they really need to be their own division,’” said Dr. Hochman, who is also an associate professor of medicine at the NYU Grossman School of Medicine.
The pandemic was also the catalyst behind the July 2020 launch of the new division of hospital medicine at Johns Hopkins Hospital in Baltimore. “But I don't necessarily think that it was because of some increased value that people saw in hospitalists so much as the practicality of needing to be nimble,” said Daniel Brotman, MD, FACP, a professor of medicine who has directed the hospitalist group since 2005 and is now director of the division of hospital medicine.
The practical need was to hire some one-year physicians to help handle the COVID-19 pandemic, which was a challenge while hospitalists were housed under a large GIM division, he said. “We were getting bigger, GIM was bursting at the seams in certain respects, we needed to be nimble and work with the health system,” Dr. Brotman said. “That extra layer had always been a little bit of a challenge, but in the era of COVID and needing to move quickly, it became a bigger challenge acutely.”
GIM division director Jeanne Clark, MD, FACP, thought it was a good idea for hospital medicine to be a separate division, he noted. But a major concern was how the new hospital medicine division would continue to foster academics.
“General internal medicine at Hopkins had really done a wonderful job building certain elements of academic infrastructure, and the conditions that I put forth for becoming our own division included continuing to access some of that infrastructure,” Dr. Brotman said. “So I think that that made it a less challenging transition.”
The transition has brought up some déjà vu for Dr. Brotman. Around 2010, hospitalists at the Johns Hopkins Bayview campus decided to become their own division. But when then-GIM division chief Myron “Mike” Weisfeldt, MD, FACP, offered him the same opportunity, he declined for a few reasons.
“One was that I didn't think we had the academic maturity to do that effectively. Another reason is we weren't that big. … And another one, frankly, was that we really had a sense of belonging in the division of general internal medicine,” Dr. Brotman said. “In some respects, that was the hardest thing to give up when we formed our own division.”
A similar split happened at the University of Nebraska Medical Center in Omaha in November 2020, when hospital medicine separated from GIM and formed a new division. But it had taken quite some time for the hospitalist team to grow to that point (and for hospital leaders to appreciate their added value), said Thomas Tape, MD, MACP, who was then chief of the GIM division.
“The first people I hired that I called ‘hospitalists' came around 2003, and it really took them a while to find their niche,” he said, recalling initial pushback against his efforts to hire more than the first four hospitalists.
The idea to create a new hospital medicine division was in the works for several years under the leadership of Dr. Tape and Rachel Thompson, MD, FACP, then the section chief of hospital medicine, according to Chad Vokoun, MD, FACP.
“They kind of agreed that [because of] the size and the logistics, and really the divergence of practice, it was probably the right idea,” said Dr. Vokoun, one of the original hospitalists who became division chief for hospital medicine after serving as the interim hospital medicine section leader in GIM. “And I'll be honest: I think we could have gotten along and figured it out. I know some of the highest functioning groups in the country are still under GIM. But for us, I think it just made sense to make a split.”
Although GIM and hospital medicine share resources and an interest in quality improvement and research, they have different areas of focus, said Dr. Vokoun, who is also associate program director of the internal medicine residency. “When I think about my operations and what we need to do in the hospital and those kinds of things, it's just a completely different ballgame than what they're doing.”
Not that the split has driven a wedge between the two divisions. “We still work side by side. Actually, my office is right next to the division chief office for GIM, and there is so much crossover because we take care of their patients and then hand them back to them,” Dr. Vokoun said. “So even though we're separate divisions, we still are kind of joined at the hip, in a way. And that's good—that's the way it should be.”
New division, new vision
Starting a new division offers both challenges and opportunities. At the University of Nebraska, it's enabled the hospital medicine leadership to make more rapid changes, Dr. Vokoun said.
“We can just be quicker and more agile to be able to move and change, and we definitely saw that with COVID with the build of our telehealth platform, and we started a postacute service that does telehealth visits for patients,” he said. “I'm not saying we couldn't have done that as a section under GIM, but we were able to just make that decision and go.”
Dr. Vokoun said being a division chief gives him significantly better visibility to support the division's clinical and research areas of interest in twice-monthly meetings with all the division chiefs within the department of medicine. “I can text our CEO and our CMO, and they'll text me back, and I've got great support there,” he said.
For example, Dr. Vokoun recently participated in a discussion of plans for the hospital's innovative design unit, anticipating what a hospital room (and its technology) will need to look like 10 to 20 years from now.
“I think back to how things have changed since 2004 when I started, and so the next 18 years that will still be part of my career, I can't imagine what things are going to look like,” Dr. Vokoun said. “I love that thought, and I love to think big and think forward and then involve my awesome team in designing that type of change.”
On the challenge side, there's the youth of hospitalists, said Dr. Hochman. There is limited mentorship in NYU Langone's new division: Of 119 hospitalists, all but seven are assistant professors. “There's zero professors, seven associate professors,” she said. “And all these people are young, and I call them my change agents, and they want to make a difference in this world. But how do we mentor these people?”
To do that, the division is creating a mentorship pod program. The five pods are quality and safety, value-based medicine, information technology, education, and research.
“Basically, the most senior people of our division have been named as leaders of each of these pods,” said Dr. Hochman. The pods started meeting virtually this month to discuss projects and promote networking, mentorship, and scholarship, she said. She is also launching a peer-to-peer program where hospitalists observe each other during attending rounds or teaching sessions and provide structured feedback once a year.
The biggest challenge for the division, however, is research, Dr. Hochman said. “We need to home-grow our own researchers, and that takes time,” she said. “To kickstart it, we partner with other divisions [that already get grant funding] to try and make something happen on both ends, which is great. That's been our strategy for this past year, and it will continue to be our strategy for the next several years.”
At Johns Hopkins Hospital, the hospital medicine division continues to partner with GIM for academic resources. “If I couldn't do that, I would be a little more anxious about our academics,” Dr. Brotman said. “But the spiritual challenge was moving out of an area that felt like home for a long time.”
Now that the group is big enough, he has added leadership positions, including a wellness and faculty development director, a quality and safety director, and a director for equity and inclusion.
“Those are roles that are new; we didn't have them when we were part of general internal medicine,” Dr. Brotman said. “At some point, I think we'll also have a research director, but I feel strongly about that person having enough federally funded research under his or her belt to justify that title.”
He said the fact that more full divisions of hospital medicine are being created is good for hospital medicine in general. “I think that it suggests that it's a discipline rather than just a job, so I do think it's a positive evolution of our profession,” Dr. Brotman said.
But even though he believes a division of hospital medicine is a positive evolutionary step, this doesn't mean that hospital medicine groups should break away from GIM prematurely, he added. “I don't think that that's always the right thing to do, and our story fits in with that concept.”
Dr. Hochman believes most hospitalist programs will become their own divisions eventually. “It's a different focus, a different voice, and nothing against our colleagues and ambulatory care, but it's just become a completely different practice,” she said.
Becoming a division is also validating for a team that “keeps the hospital afloat,” Dr. Hochman said. “I keep coming back to the word ‘validated’ because you feel like, ‘I'm being seen. I'm being appreciated for all the hard work during COVID and all those years before that,’” she said. “My team has a seat at pretty much every important table at the hospital … and now I report to the dean twice a year as a division. I never had that before as a program director.”
Dr. Vokoun agreed. “I think we're here to stay and will just become more and more integral as we go forward, so I'm excited and proud to be a division chief,” he said.