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Hospital Medicine: Growing Toward Specialty Status


 

When the Society of Hospital Medicine was very young and headquartered in the home computers of myself and Win Whitcomb (and known then as the National Association of Inpatient Physicians), I spent a lot of time thinking about the future of our field. Whether we would, or should, become a recognized specialty was one of the things I particularly enjoyed thinking about. Believing the history of Emergency Medicine might provide some insights for Hospital Medicine, I tracked down Dr. John Wiegenstein, who played a major role in the founding of the American College of Emergency Physicians (ACEP) in 1968, served as the group’s first president, and helped mold Emergency Medicine into a distinct specialty recognized by the American Board of Medical Specialties.

The parallels between the first few years of Emergency Medicine and Hospital Medicine are striking (see Table 1, milestones in Emergency Medicine). Dr. Wiegenstien told me that there was tremendous enthusiasm among early ACEP members for the opportunity to create a new specialty and invent the systems of care in the emergency room (now department) that would best serve patients and the overall enterprise of health care. At the time of ACEP’s founding, there was no group that was primarily devoted to ensuring that emergency rooms were held to high standards of care and operated efficiently. In the late 1960’s, when ACEP sought to fill this void, Dr. Wiegenstein said that the medical leaders of the day in the AMA and other organizations, tended to smile patronizingly, pat him on the shoulder figuratively, and suggest that it would be fine to busy himself with such a project since it would keep him and his colleagues out of the way of those who were doing the important things in medicine. After all, the leaders of the day reasoned, there were already existing specialties with more expertise at any kind of care that an ER doctor might provide, so creating a new breed of doctor or specialty seemed like it would be an unnecessary duplication of existing specialties. Yet Dr. Wiegenstein and his colleagues did exactly what they set out to do, and today there is probably no one who questions the importance of the contribution of Emergency Medicine to our healthcare system, and its status as a distinct specialty.

Table 1. Milestones in the history of Emergency Medicine (from ACEP News, Vol. 18, No. 9, September 1999) click for large version

click for large version

The case for Hospital Medicine becoming a recognized specialty or subspecialty.

The question for those of us in Hospital Medicine is should we, and can we, be about doing the same thing in our field that has happened, and is ongoing, in Emergency Medicine? I suspect nearly all hospitalists believe the answer is yes, and I sense growing support for this goal from those in nearly all other fields in medicine. And I think an important factor in ensuring success is to think of ourselves as a distinct specialty or subspecialty.

In fact, Hospital Medicine functions as a distinct specialty in many respects already. There is a growing body of distinct literature about clinical and operational aspects of hospitalist practice, distinct educational materials and CME courses, and an active and growing professional society. Hospitalists are taking leadership positions in developing optimal systems of inpatient care in many institutions. And SHM is now working to launch its own journal of Hospital Medicine.

What existing specialties have that Hospital Medicine does not (yet) is certification criteria, including an exam, and separate credentialing categories in hospitals and payer organizations such as Medicare. While I’m not eager to take or pay for another certifying exam myself, it would help to maintain high standards among hospitalists and encourage focus on the core competencies in Hospital Medicine. It would shape residency training and CME courses as well. At the outset, and maybe permanently, I envision a Hospital Medicine exam (with versions for pediatric and adult medicine hospitalists) as a certificate of added qualification to the existing board exams in Internal

Medicine, Family Practice, and Pediatrics. The American Board of Internal Medicine (ABIM) has developed criteria regarding when to develop a certificate (exam) in a new field (Table 2), and if/when Hospital Medicine passes that step, it will be time to think about whether Hospital Medicine should move up the hierarchy of specialization to become a recognized subspecialty of Internal Medicine. But the process of “sanctioning” a new certificate (exam) or subspecialty is a complex one, and many fields initiate it on their own; which for Hospital Medicine might mean doing so without the distinct approval or input of the ABIM or American Board of Medical Specialties (ABMS) at the outset. Once a field’s own efforts gain legitimacy, then the ABIM and ABMS often recognize it as a distinct specialty or subspecialty. Such was the path taken by Emergency Medicine and many other fields.

I see a process of becoming eligible for the exam by completing residency training in IM, FP, or Pediatrics, and working as a hospitalist for a specified period of time (e.g., 3 years). Those who meet these (and other?) criteria, and pass the exam, could benefit from increased prestige and stature, and better differentiate themselves from doctors who might call themselves hospitalists but not have the delivery of inpatient care as their primary professional focus. Research studies of hospitalist systems of care could benefit from a more rigorous definition of who is really a hospitalist based on certification. And a practical consequence of a growing number of certified hospitalists might be an improved ability to lobby for adjustments and improvements in the professional fee reimbursement for inpatient care.

Patients indicate that board certification is very important when choosing a doctor (1), so being able to show them that I am a certified practitioner in a recognized specialty will have value. Of course, all hospitalists have the opportunity to show patients (e.g., on a business card or stationary) board certification in the specialty of their residency training, but the ability to demonstrate additional competence and dedication to Hospital Medicine will be valuable in the same way it is valuable for other fields with certificates of added qualification such as Sports Medicine, and Geriatrics.

Other features of a distinct specialty usually include things such as recognition in the AMA as a section; in the case of hospitalists a Section on Hospital Medicine. Such recognition would add legitimacy to the field and provide a stronger platform from which to lobby for the needs of our patients and our discipline. And with these credentials Hospital Medicine can relate to other specialties or subspecialties as peers rather than as a fledgling upstart.

Table 2. ABIM Criteria to Develop Certificate (Exam) in a New Field click for large version

click for large version

Costs of specialty recognition.

Some fear that developing an exam in Hospital Medicine will lead payers, which are usually enthusiastic supporters of the hospitalist movement, to discriminate between those who are and are not exam certified. In other words, if a payer has access to a group of certified (passed the exam) hospitalists, it might refuse to contract with non-certified PCPs to provide inpatient care. In this way the exam could be used as a way to restrict the practice of those who have not taken it, rather than simply enhancing the competence and stature of those who have passed it. I think there are many forces in medicine that would prevent this from happening to any significant degree. The history of many other specialties shows that an effort to restrict practice to certified doctors takes many years to gather steam (e.g., Emergency Medicine). And payers would only hurt themselves by restricting themselves to certified hospitalists early on, since it will likely be many years before the supply would be adequate to ensure enough doctors are available to do the work.

Something I hear often, and sometimes think myself, is “doesn’t medicine have enough specialties already?” After all, at the hospital where I practice the orthopedic doctors are segregated into those that focus on sports medicine, or the upper vs. lower extremity. Even though I know all of these orthopedists fairly well, I have a great deal of trouble remembering who is the knee person, and who to call for shoulders. If every traditional field in medicine continues to divide and subspecialize there is an increasing risk that we will grow further apart and have a harder time relating to each other professionally, and even more difficulty presenting a unified voice of all physicians before legislators or the public? I am very concerned about this problem, and do not see a simple solution. But concern about a potential “Tower of Babel” in medicine with many specialties which don’t speak the same language is not a good reason to inhibit specialization and increased expertise of any one group. The way to address this problem is through things such as improved mechanisms of communication.

Most patients believe our medical system clearly benefits from the existence of many different specialties. Few would want to go back to the system of limited physician specialization of 50 years ago. It seems likely that a person living in the middle of the last century would have all of their medical needs addressed by one or two doctors throughout their life (e.g., an internist or general practitioner, and possibly a surgeon at some point). That led to terrific patient-physician continuity for much of the population. And that continuity has been dissolving over the last 30 years, in large part due to the explosion of new specialties in medicine as well as economic forces and other factors. But I’m reminded regularly that patients want to see a number of different specialists at different times during their life, even if that means they see less of their primary care doctor (PCP) and have less overall continuity of care. After all, if a patient learns from her PCP that she needs to have her gallbladder removed, she isn’t likely to lean toward the PCP and say “You’re the doctor I know best, and I want you to take our my gallbladder instead of having it done by a stranger I’ve never met.” Instead patients say the opposite: “Send me to a doctor I’ve never met, but one who is an expert (experienced and board certified) in taking out gallbladders.”

So I think that we simply need to accept that increasing subspecialization is going to be part of our health care system for the foreseeable future. Rather than trying to resist or reverse it, we should simply be careful not to grant new subspecialty status too quickly. And all doctors should make sure that they spend time and energy focused on ensuring that doctors of all specialties maintain effective methods of communication about patients they care for together. Hospitalists will play an important role in this since ours is a specialty based on a site of practice rather than a particular disease or organ system. Like other generalists, such as PCPs and Emergency Physicians, we will be part of the glue that connects physicians by regular interaction with doctors from a wide variety of specialties.

We should also think about the effect a specialty of Hospital Medicine would have on the broader primary care community. For example, the American College of Physicians (ACP) has watched the birth of a number of medical subspecialties in the last 40 years, and most practitioners in each specialty have moved away from the ACP as their professional society and to their own subspecialty organization. This has led to a fracturing of internal medicine into many subgroups such that it might not be unusual to find one internal medicine subspecialty group arguing with another, rather than all speaking with one voice through the ACP. Each group has lost some clout and effectiveness as a result. But Hospital Medicine is still a generalist specialty (based on the site of care), unlike subspecialties such as cardiology and infectious disease, and should maintain a close connection with the ACP. If the formal recognition of Hospital Medicine as a specialty significantly dissolves the connection between ACP and SHM then both groups stand to lose a great deal. The leaders of these groups will need to work diligently to prevent this.

In my friend Mark Aronson’s accompanying article, “Be Careful What You Ask For,” he makes very reasonable proposals for what I see as intermediate steps toward specialty status. And he makes good points about some risks of becoming a specialty. I think we should move somewhat slowly toward specialty status so that the concerns he identifies can be addressed. But rather than identifying issues that are unique for Hospital Medicine, he has listed questions that probably arose in the formative years of every specialty and were subsequently addressed as the field “grew up.” He uses the example of electrophysiology as a field that requires additional training beyond the standard cardiology fellowship, and he suggests that it is the additional training that justifies the field’s exam and subspecialty status. But at some point in the early evolution of electrophysiology and any other field, there was no unique training program and practitioners learned the discipline through things such as self study, CME courses, and concentrating their practice on that clinical area. Isn’t that where we find ourselves in Hospital Medicine today?

Summary

The benefits of continued movement toward recognizing Hospital Medicine as a distinct specialty outweigh the costs. Indeed, without ever having an organized effort or agenda for this, our field has made many significant steps in that direction. What will require ongoing careful consideration is the pace at which the next steps in maturation of the field should proceed. While there are sure to be many differences in the path Hospital Medicine takes to specialty status, there are numerous lessons to be learned from the history of other specialties, such as Emergency Medicine. In 1969, Dr. John Wiegenstein wrote in the first Newsletter of the American College of Emergency Physicians that “We are, in a sense, a new breed of doctors dedicated to a new concept of medicine.” Most hospitalists feel the same way about Hospital Medicine, and I think we will mark very similar milestones toward specialty status in the coming years.

Reference

  1. Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The Role of Physician Specialty Board Certification Status in the Quality Movement. JAMA.2004;292:1038-43.

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