Becoming a Hospitalist: Is Additional Training Necessary?

Hospitalists constitute the fastest growing medical specialty in the United States, attracting in?creas?ing numbers of both newly minted and more seasoned doctors every year. Previous research demonstrated that hospitalists can save hospitals money and provide good quality care. One issue that has not been resolved is whether physicians who have already completed a residency in internal medicine (IM) or family medicine should be required to do extra training in hospital medicine and take subspecialty boards to become hospitalists. Few leaders of the movement think that completing a separate fellowship is necessary, but many support the idea of additional training.

Many hospitalists acknowledge that IM training falls short of preparing physicians for certain hospital duties. According to Chad Whelan, MD, director of the Hospitalist Scholars Training Program, University of Chicago, "current residency programs don't adequately train people to be hospitalists."

IM programs do not provide training beyond the care for individual patients with specific disorders. "Residents are underexposed to quality issues and to thinking about health care systems?a more institutional approach to caring for patients," said Dr Whelan. And because hospitalists are taking the lead in quality improvement and streamlining the delivery of care, this part of being a hospitalist must be learned on the job.

To better prepare residents to provide hospital care, the Society of Hospital Medicine (SHM), together with the American College of Physicians and other medical societies, has developed a set of core competencies, which appear as a supplement to the inaugural issue of the Journal of Hospital Medicine (2006;1[suppl1]:48-67). Laurence Wellikson, MD, FACP, chief executive officer of the SHM, says the society hopes that the American Board of Internal Medicine will adopt these guidelines.

While underscoring the need for core competency requirements, Dr Wellik?son stressed that the SHM does not advocate an additional fellowship for IM residents who would like to be hospitalists. "We don't anticipate that you will need a fourth year of training," he ex?plained. Instead, he advocates re?struc?turing the residency training programs, with all residents receiving the same training for 2 years and those who want to be hospitalists then receiv-ing more hospital training in their third year.

Dr Wellikson notes that hospitalists need to develop management skills. "Our view is that hospitalists are much more integrated into how the hospital functions." He also be?lieves that hospitalists should play a role in improving how hospitals function and work with other departments (ie, pharmacy and nursing).

Research evaluating the effectiveness of hospital medicine?trained physicians can help shed light on the issue of additional training. David O. Meltzer, MD, PhD, associate professor in the Pritzker School of Medicine, the Department of Economics, and the Harris School of Public Policy Studies at the University of Chicago, has been studying whether hospitalists improve patient outcomes and lower medical costs. Using his dual expertise in economics and medicine, he questions the benefits of creating a subspecialty devoted to the care of hospitalized patients. While he notes that research supports the idea that specialization makes sense, Dr Meltzer believes that there is a downside to instituting too many requirements for hospitalists.

"People who generally do ambulatory practice may do a good job in the hospital setting," notes Dr Meltzer. And creating barriers may prevent certain doctors from practicing as hospitalists. Dr Meltzer is currently completing a randomized trial comparing hospitalists with traditional physicians in 6 academic medical centers. He challenges earlier research that showed hospitalists curb spending. "A subspecialty that controls training controls entry and may drive up prices for their services, and this may not be good for patients." Dr Meltzer concluded that patients must be followed over a longer period of time to fully evaluate how effective hospital physicians are at improving outcomes and cutting costs.

Suman R. Ranji, MD, of the Uni?versity of California, San Francisco, and lead author of an article on ?fellowships for hospitalists (Am J Med. 2006;119:72), concurred that most ?hospitalists do not need additional ?training. He told IMWR that "graduates of ?internal medicine and pediatrics ?re?s?i?dencies are perfectly qualified for clinical hospitalist positions without completing a fellowship." Those relatively few ?IM residents interested in pursuing a career involving research should consider an academic hospitalist fellowship, which is available at various academic medical centers across the country. He also noted that requirements for a career as a ?hospitalist could change in the future ?as the job market becomes more competitive.

Currently, physicians qualify to work as hospitalists upon completing standard residencies in IM, pediatrics, or family practice. But as the field of hospital ?medicine ?continues to expand, national boards may require additional training for physicians who want to work in this field. imwr

Separate Certification Requirements for Hospitalists

As the popularity of hospital medicine continues to grow, the American Board of Internal Medicine (ABIM) is considering creating a separate certification process for hospitalists. This certification would focus on the inpatient medicine skills that hospitalists would need to treat their patients.

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, and the first elected president of the Society of Hospital Medicine, explained to IMWR what the ABIM is considering. "The discussions here at the ABIM are focusing on the possibility of recognizing focused practice in hospital medicine at the time of maintenance of certification."

According to Dr Wachter, the ABIM and other stakeholders are considering making changes after a physician completes internal medicine residency training, takes the ABIM internal medicine boards, and begins practice.

"Individuals whose practice was focused on hospital medicine (in a way still to be defined, but it would have components of inpatient volume and quality measures) would accumulate a portfolio of information demonstrating their experience and expertise, and would then take an exam that would be hospital medicine focused," he said. Physicians would be eligible to go through this process after a few years of practice, not the usual 10 years required for recertification. He added that the ABIM is considering a parallel path for ambulatory medicine practitioners.

Dan Duffy, MD, executive vice president of the ABIM, explained that the board does not regard hospital medicine as a new discipline. Nevertheless, the board "wants to recognize what people do in practice."

The ABIM has met several times in the past year with the American College of Physicians, the Society of Hospital Medicine, and hospital administrators to define what a focused practice in hospital medicine actually is. Dr Duffy stressed that any certification process that might come out of these talks would be designed to improve patient care, not to exclude physicians who might do some hospital medical care along with some ambulatory care. With regard to physicians practicing in smaller hospitals or very specialized physicians in larger hospitals who may provide both inpatient and outpatient care, Dr Duffy said the board recognized that there may be instances in which "the best situation is having the same internist managing the patient all the way through."

Proposed changes to the certification process are still in the planning stages, but "the ABIM is committed to making sure that all stakeholders are informed," Dr Duffy said. ?S.P.L.