Hospitalist Training Program
The hospitalist training program (HTP), which commenced in July 2004 and is the oldest operating comprehensive hospitalist training program in the country, strives to take a novel approach to preparing residents for a future as a hospitalist or primarily hospital-based specialist. The program, built on data showing that internal medicine trained hospitalists are generally under-prepared in several key areas, addresses important educational and mentorship needs. At the conclusion of the program, graduates are well prepared to function clinically as a hospitalist also to act as leaders and change agents in improving healthcare systems.
The HTP is available to up to 24 residents and there are two pathways within the HTP. The Traditional Track accepts applications toward the end of the intern year for entry into the two-year program that commences after a standard categorical intern year. This pathway expertly trains learners to become outstanding hospitalists with special emphasis on quality improvement, patient safety, hospital efficiency and system redesign. There is an additional focus on healthcare finance, the business of medicine and the development of basic leadership skills.
Starting in 2011 there will be a limited number of positions available at the intern level through the NRMP Match. This Leaders Track enrolls HTP residents in a three-year program commencing at the intern level and is geared towards those learners looking to take on major leadership roles in hospital medicine, quality improvement or hospital administration. The Leaders Track includes additional non-clinical offerings in the intern year prior to joining the Traditional Track residents for the second and third year curricula.
Both pathways utilize the backbone of the categorical track rotations such that residents are integrated into the overarching residency program and graduate with expertise in both in- and out-patient medicine. However, the HTP substitutes track-specific clinical rotations for other general medical rotations to tailor the training to the needs of future hospitalists. The HTP also includes immersion training in quality improvement, patient safety and hospital efficiency with an emphasis on mentored implementation of quality improvement projects. Additional program features include an individualized mentorship program, a hospitalist-focused journal club, a monthly project conference that affords the housestaff the chance to utilize the key tools and tenets of hospital medicine, opportunities to publish and present work at a regional and national level and biannual retreats (Fall in Vail, Colorado; Winter in Winter Park, Colorado).
Hospitalist residents work closely with University of Colorado hospitalist faculty and are exposed to an innovative curriculum during their hospitalist rotations. Current rotations include a Hospitalist Preceptorship month that teaches residents the key curricular and structural components to be an outstanding hospitalist. The Consultative and Perioperative Medicine rotation offers ample opportunity to learn the tenets of co-management of surgical patients, medical consultation and acute stroke management. While rotating on the inpatient Acute Care for the Elderly service, hospitalist residents will learn how to expertly care for frail elderly patients, including the importance of care transitions. Finally, all residents design and implement a process or quality improvement project culminating with a one-month Quality Improvement rotation. Many residents have turned this activity into scholarly activity, giving them a head start on an academic career. All rotations are available as electives for those who are not in the program
Residents spend one month during their second and third year on the preceptorship rotation. During this month the resident has one-on-one interaction with a hospitalist faculty member rotating in a hospitalist model of care. While on service they staff new admissions and consultations daily, work with a multi-disciplinary team and learn first-hand about hospital systems of care and quality improvement. A daily didactic curriculum focuses on learning and understanding the hospital system and the hospitalists' interaction with it.
Specific Topics in Preceptorship Curriculum:
Medical billing and coding
Hospital efficiency and throughput
Implementing patient safety measures
Working with Advance Practice clinicians
Transitions of care for the Un/Underinsured
Consultative, Perioperative Medicine and Stroke
Residents spend one month during their second and third year on the consultative and perioperative rotation. Data supports that nearly one-third of a hospitalists' job consists of consultative, perioperative and neurological work.This rotation stresses the co-management model of care whereby patients are seen collaboratively with our orthopedic and neurologic colleagues. Additional consultative work is provided to other non-medical services. Daily didactics stress key issues such as the pre-operative cardiac and pulmonary evaluation, perioperative diabetes and steroid management, the prevention of post-operative venous thromboembolism and the management of post-operative fever. The neurology component stresses the medical management of the acute stroke patient. As a member of the Acute Stroke Team, HTT residents see first-hand the presentation and amanagement of acute ischemic and hemorrhagic strokes. Neurology-traidend hospitalists guide the residents through the physical exam, imaging interpretation and management of acute stroke and TIA. These clinical offerings are complemented by didactics surrounding secondary prevention and hypertensive and glycemic control as well as general neuroanatomy and the physical exam. Other acute neurologic disease states are covered as well.
Specific Topics in Consult & Perioperative Medicine Curriculum:
- Perioperative evaluation, including Cardiac and Pulmonary evaluations
- Perioperative care, including glycemic control and steroid management
- Prevent care in the Perioperative period, including delirium and venous thromboembolism
- Principles of co-management
Acute Care for the Elderly
Recognizing that 20% of the population will be over the age of 65 years old and that this population suffers the highest burden of hospital avoidable harm, we have developed an inpatient geriatrics rotation focused on improving care of this vulnerable population.
All HTT residents rotate on this hospitalist-run service in the 2nd year. A formal curriculum in hospital-based geriatrics has been developed and is taught through out the course of the month. Additionally, resdients round with a multi-disciplinary team, which includes geriatricians, physical therapists, social workers, pharmacists and nurses all focused on improving the care we give to our elderly poplulation. The ACE service aims to integrate a vulnerable population, a multi-disciplinary team and the learners burgeoning skills in process improvement to produce rapid tests of change, PDSA cycles and in-depth process improvement projects to ultimately provide the saftest, highest quality of care.
Specific Topics in the ACE Curriculum:
- Physiology of Aging
- Medications in the Elderly
- Dementia and Delirium in the Elderly
- Advanced Directives and Resuscitation
Palliative care and end-of-life decision making are domains of hospitalist practice. Still, few hospitalists have formal training in these areas. The palliative care rotation incorporates both inpatient and outpatient palliative care with dedicated didactics to help improve this educational and experiential mismatch. The rotation is a perfect complement to the annual palliative care retreats.
Specific Topics in Palliative Care Curriculum:
- End-of-life decision making
- Pain and symptom management
- Determining decision-making capacity
- The hospice benefit
- Coordinating transitions of care
Quality and Systems Improvements
As part of the longitudinal QI curriculum present throughout the HTT track, this month provides HTT residents dedicated time to deepen their understanding of quality improvement (QI) principles and implement their projects. Higher level teaching sessions are provided throughout this month which are complemented by QI coaching for each QI team. Residents are able to put into effect small tests of change in a live environment. This month serves to cement knowledge and skills residents have gained through authentic experience in QI.
Specific Topics in Quality and Systems Improvement Month:
- Tools for quality improvement
- Interpreting quality data
- Graphical presentation of change data
Hospitalist Training Track Curricula
The promise of the hospital medicine movement is that hospitalists will provide higher quality care. However, this will not done by simply becoming better clinicians, rather through systematic quality improvement. Therefore we have developed a comprehensive curriculum focused on providing future hospitalists with the knowledge and skills required to become successful change agents in patient safety and quality improvement. Delivered in twelve, 4-hour sessions, the curriculum covers concepts of quality improvement, patient safety, the business of medicine, medical education and health care policy as they pertain to a practicing hospitalist. The teaching sessions also provide leadership skills that will enable our graduates to translate their patient safety and quality improvement knowledge into actionable process improvements. The sessions are highly interactive, informative and fun. Residents have the opportunity to apply the skills learned during these sessions during their formal, mentored QI project time. In the end, residents graduate well prepared to immediately improve the healthcare systems they enter as hospitalists.
Specific topics in the HTT Longitudinal Curriculum:
- Quality improvement, including Tools of QI, Leading change and Implementing tests of change. Residents apply the knowledge and skills learned during QI rotation
- Business of Medicine, including Business Drivers, Understanding Financial Statements, and the CEO's mindset
- Health Care Policy, including the Role of the Physician in Health Care Policy, Understanding Medicaid and Medicare, and a visit to the Colorado State Capitol
Career Development Curriculum
As part of the longitudinal curriculum, the program prepares future hospitalists for the rigors of attaining and succeeding in their future profession.
Specific topics in Career Development Curriculum:
- Developing an effective curriculum vitae
- Techniques for successful job interviewing
- How to approach contract negotiations
- Differentiating academic and community hospitalist jobs
Quality Improvement Curriculum
All HTT residents participate in a longitudinal quality improvement project with the University of Colorado Hospital. The faculty-mentored QI project provides the experiential component to the 2-year curriculum, which includes an elective month dedicated to QI. The didactic curriculum covers the key tenets of QI and patient safety and teaches residents how to develop, implement and measure a QI project. The goal is to inspire and equip physicians to function as change agents in their future roles as hospital leaders.
The cornerstone of the QI curriculum is experiencing quality improvement first-hand as change agents for a quality improvement project at the University of Colorado Hospital (UCH). HTT residents work on a team-based project along with University Hospital stakeholders to improve hospital processes. The projects are closely mentored by hospitalist faculty with additional QI expertise and support from the group at each step of the project.
Recent Quality Improvement Projects:
- Reducing Informal Restraints in the Frail Elderly Patient. Faculty mentor: Heidi Wald, MD
- Improving Quality and Timeliness of Residents' Discharge Summaries. Faculty Mentor: Darlene Tad-y, MD
- System Redesign to Achieve Rapid Thrombolytic Treatment of Stroke: Applying Interdisciplinary QI Principles to Treat Patients in the Golden Hour. Faculty mentor: Ethan Cumbler, MD, FACP
- Physician-centered Initiative to Reduce Inpatient Falls at the University of Colorado Hospital. Faculty mentor: Dimitriy Levin, MD
Hospitalist residents are provided ample opportunities to participate in scholarly activities.
This monthly conference allows HTT residents to use the basic concepts they are learning. All residents rotating on a hospitalist month present a short project to the HTT residents and hospitalist faculty. Conferences are themed around important tenets of hospital medicine such as patient safety, healthcare finance, hospital efficiency, healthcare policy and quality improvement.
Residents are allowed to use 1-2 months during their residency toward completing a research project. Several hospitalist residents have chosen to work with our hospitalst faculty on hospital-based clinical research and quality improvement research projects.
In addition to traditional clinical research, HTT residents also participate in systems redesign and process improvement projects in various settings within the hospital. Residents are not limited to the longitudinal QI project built into the HTT track.
Recent HTT Resident Scholarship
Borne R, Cumbler E, Glasheen JJ. Reducing polypharmacy: is hospitalization the right time? Arch Intern Med. 2011 May 9;171(9):869; author reply 870.
Research/Innovations Abstract Presentations
Anderson M, Go A, Levin D. Proton pump inhibitor use in hospitalized medical patients. Society of Hospital Medicine National Meeting, Dallas, Texas. 2011. Poster.
Mertz C and Zehnder N. Epidemiology of Social Delays in Discharge. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Guerrasio J, Cumbler E. Anderson M, Guiton G, Hodgson C, Aagaard E. A Computerized Patient Case Simulator: A Window Into How We Think. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Anderson M, Go A, Levin D. Proton pump inhibitor use in hospitalized medical patients. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Vignette Abstract Presentations
Harrington K, Coffey D, Levin D. Anasarca of an unusual etiology. Society of Hospital Medicine National Meeting, Dallas, Texas. 2011. Poster.
Jennings K, Cumbler E. Signs of Catastrophe: Characterizing Acute In-hospital Strokes. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Hodges S, Lavelle J, Cumbler E. Not Your Mothers Gallstones. Recurrent Cholangitis Associated with Bilirubin Stones. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Dalton K, Tad-y D, Cumbler E. A Penetrating Etiology of Chest Pain. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster. -Semifinalist QuantiaMD/Journal Watch National Case Challenge Competition.
Harrington K, Coffey D, Levin D. Anasarca of an unusual etiology. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Sleesman J, Zehnher N, Misky G. Wading without Waders: A Dangerous Endeavor. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Sweigart J, Wolfe B, Chen E. Cavitary Lung Lesion as a Herald for Malignant Thromboembolism. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Reichelt K and Glasheen J. Performing Under Pressure. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Miles M and Zerzan J. Bad Trip: An Acidotic Misadventure. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Inman R, Kern D and Pell J. An Uncommon Cause of Cortical Vision Loss and Progressive Neurological Decline. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Harry E, delPino-Jones A, Tad-y D, Glasheen J . Air Under the Diaphragm? Not Always an Indication for Surgery… Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2010. Poster.
Zaemisch R, Graves A, Jones W, Cumbler E. Improving the Quality and Timing of Inpatient Stroke Alerts. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2009. Poster.
Hubbell S, Bridenstine M Frank M, Janssen W, Maloney J. Rash, Renal Failure, Regurgitant Murmurs, & Ruptured Aneurysms: Getting to the heart of the matter. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2009. Poster.
Hubbell, S and Zehnder, N. No Stones About It: Renal Infarction Mimicks Renal Colic. Rocky Mountain Hospital Medicine Symposium, Denver, Colorado. 2009. Poster.