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BACKGROUND: The field of hospital medicine is growing rapidly in academic medical centers. However, few organizations have explicitly considered the opportunities for and barriers to hospital medicine's development as an academic field in internal medicine. OBJECTIVE: The objective was to develop consensus around key areas limiting or facilitating hospital medicine's development as an academic discipline. DESIGN: The design was a consensus format conference of key stakeholders in academic hospital medicine. RESULTS: The consensus group identified several issues impeding the development of academic hospital medicine as a recognized entity in academic settings, including extraordinarily rapid growth, increasingly preponderant nonteaching roles, and demands to perform nonclinical duties (such as quality improvement) not generally viewed as academic pursuits. The consensus group developed recommendations for addressing these concerns, specifically: 1) characterizing the optimal job description for an academic hospitalist, 2) developing better local and at-a-distance opportunities for training academic hospitalists in key aspects of early career success, and 3) advocating for the development of fellows and junior faculty researchers in hospital medicine. SUMMARY: Fostering academic hospital medicine will help address these issues more effectively and will help the field while also attracting the next generation of generalists needed to care for an increasingly complex inpatient population. Journal of Hospital Medicine 2009;4:240–246. © 2009 Society of Hospital Medicine.

While just 10 years ago the health system largely relied on paper, today nearly all hospitals and three-fourths of office-based physicians are using certified electronic health records (EHRs), in part, as a result of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.1 Moreover, thanks to the Affordable Care Act, more than 90% of Americans now have health insurance, meaning we now have the opportunity to have a clinical record of our care experience that can support longitudinal follow-up and improved population-level surveillance.2 Looking forward, we can clearly envision a health care landscape where data are abundant and flowing and used to guide care delivery decisions—a learning health system described in our Nationwide Interoperability Roadmap.3

Mega-disasters the scale and scope of Hurricane Katrina have been exceedingly rare in the USA. Nonetheless, careful study of such disasters can provide lessons learned that can lend essential insights to guide planning for future events of any size.1 Such disasters can also expose previously under-recognized frailties in society that, like the under-built levees of New Orleans, readily buckle under stress. One such frailty exposed by the storm was the health care safety net. Katrina was in many ways the “perfect storm” not only because of her meteorological characteristics but because she struck a portion of the world with high prevalence of chronic conditions, high rates of uninsured, and a geographically and financially consolidated safety net system.2 At the heart of the devastated area was the Medical Center of Louisiana at New Orleans (formerly known as Charity Hospital), the primary source of first-contact and chronic disease care for hundreds of thousands of uninsured and underinsured persons in the Greater New Orleans area. Katrina’s devastating flood rendered this Center completely inoperable. This confluence of events left hundreds of thousands of vulnerable patients with chronic conditions in the most densely populated hurricane-affected areas suddenly with no access to care. In this issue of JGIM, the Hurricane Katrina Community Advisory Group present the findings of their telephone survey assessing the impact of Hurricane Katrina of survivors with chronic disease among a sample from New Orleans and other affected areas.3 In their large representative sample, one in five persons reported having cut back or terminated treatment for a major chronic illness after the hurricane. Characteristics independently associated with treatment disruption included age younger than 65, having fewer relatives within and beyond hurricane-affected areas, and suffering two or more geographic relocations by early 2006, roughly 4–6 months after the disaster. Insurance was not an independent predictor in multivariable analysis, but this variable may have been difficult to disentangle from age, given the role of Medicare. Their complementary listing of respondents’ self-reported reasons for treatment interruption highlighted limited access to physicians and medications, insurance/payment issues, and competing demands for patient’s time and attention. These factors are strikingly similar to those reported in research among Americans experiencing homelessness in the absence of major humanitarian disasters.4,5 Minimizing disruption to the care of persons with chronic disease requires weaving a health care safety net resilient to the stress of disasters and to the more personalized disasters such as job loss or loss of one’s home.6 The design of a resilient health care safety net should pivot on recognition that continuing care for patients with chronic illness and their associated complex needs requires sufficiently nuanced policies. We posit that a health care safety net, capable of caring for patients with chronic disease during routine times and disasters, must take account not one, but three types of “homes”, each interdependent and supporting the other. Health care policies to shore up the safety net should drive the development of a web-enabled “medical home”,4,5 a portable financing mechanism for their care, an “insurance home”, and sufficient social support and resources to allow for self-care and management sufficient to help them respond to life’s challenges, a “social home”.

Hypertensive African Americans often respond poorly to beta-blocker monotherapy, compared with whites. There is evidence, however, that suggests that this response may be different if beta-blockers with vasodilating effects are used. This 12-week, multi-center, double-blind, randomized placebo-controlled study assessed the antihypertensive efficacy and safety of nebivolol, a cardioselective, vasodilating beta1-blocker, at doses of 2.5, 5, 10, 20, or 40 mg once daily in 300 African American patients with stage I or II hypertension (mean sitting diastolic blood pressure [SiDBP] > or =95 mm Hg and < or =109 mm Hg). The primary efficacy end point was the baseline-adjusted change in trough mean SiDBP. After 12 weeks, nebivolol significantly reduced least squares mean SiDBP (P< or =.004) at all doses of 5 mg and higher and sitting systolic blood pressure (P< or =.044) at all doses 10 mg and higher, compared with placebo. The drug was safe and well-tolerated, with no significant difference in the incidence of adverse events compared with placebo. Nebivolol monotherapy provides antihypertensive efficacy, with few significant adverse effects, in hypertensive African Americans.

Black women have a disproportionately higher incidence of cardiovascular disease mortality than other groups and the reason for this health disparity is incompletely understood. Underestimation of personal cardiac risk may play a role.We investigated the personal characteristics associated with underestimating cardiovascular disease in black women.Trained surveyors interviewed 128 black women during the baseline evaluation for a randomized controlled trial in an urban, academic continuity clinic affiliated with a public hospital system. They provided information on the presence of cardiac risk factors and demographic and psychosocial characteristics. These self-report data were supplemented with medical record abstraction for weight.The main outcome measure was the accurate perception of cardiac risk. Objective risk was determined by a simple count of major cardiac risk factors and perceived risk by respondent's answer to a survey question about personal cardiac risk. The burden of cardiac risk factors was high in this population: 77% were obese; 72% had hypertension; 48% had high cholesterol; 49% had a family history of heart disease; 31% had diabetes, and 22% currently used tobacco. Seventy-nine percent had 3 or more cardiac risk factors. Among those with 3 or more risk factors ("high risk"), 63% did not perceive themselves to be at risk for heart disease. Among all patients, objective and perceived cardiac risk was poorly correlated (kappa=0.026). In a multivariable model, increased perceived personal stress and lower income were significant correlates of underestimating cardiac risk.Urban, disadvantaged black women in this study had many cardiac risk factors, yet routinely underestimated their risk of heart disease. We found that the strongest correlates of underestimation were perceived stress and lower personal income.