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Be Careful What You Ask For


 

I pose here a list of questions to consider before embarking on the creation of a new specialty in hospital medicine

1) What distinguishes the body of knowledge of hospital medicine from internal medicine (or pediatrics, for our colleagues in that field)?

While there is a body of literature supporting operational aspects of hospital care, as far as I can tell there is no difference in the way a hospitalist or office-based internist should treat pneumonia. Hospitalists develop areas of expertise in case management, understanding of hospital-based quality-improvement systems, communication skills, etc, but these fall short of a body of knowledge for a medical specialty. Books on hospital medicine do not differ from standard medicine texts in terms of disease pathophysiology, clinical presentation, diagnosis, or management. What then is the new body of knowledge?

Point/Counterpoint: Should Hospital Medicine Become a Distinct Specialty?

Editor’s note: As the hospital medicine movement continued its explosive growth, it was a matter of time until discussion regarding specialty/subspecialty status began to emerge. Clear similarities between other site-specific and relatively new specialties such as emergency medicine and critical care medicine have not been lost on hospitalists. Likewise, although the preponderance of us completed residencies in internal medicine, a significant number of hospitalists are pediatricians or family practitioners, and a small but perhaps growing number are OB/GYNs and surgeons—i.e., as a group we are something other than simply internists who choose to focus on inpatients.

The following point/counterpoint is designed to further this debate, and to encourage further examination of both sides of this important and somewhat contentious issue. Mark Aronson and John Nelson take opposing viewpoints here, as they do on this issue in ‘real life’, and make cogent arguments both for and against moving toward some type of specialty status for hospital medicine. The opinions espoused by both authors are their own, and do not necessarily reflect the views of SHM. We hope this proves to be thought-provoking, and welcome your comments in response. –JP

2) Does hospital medicine really want to exclude office-based primary care doctors from managing their own cases in the hospital if they so choose?

Creating a new specialty of hospital medicine certainly would tend to do that. Let’s look at emergency medicine, for example. It used to be common for internists and surgeons to work in emergency rooms. That no longer is the case in many parts of this country because of the emergence of a new specialty. Do we want the same to be true for office-based doctors who care for their own patients?

3) Creating a new specialty requires special training. What is that going to be? Who teaches it and who will do it?

New subspecialties require additional training. For instance, electrophysiology is now a subspecialty of cardiology and requires an additional one or two years of training after a three-year cardiology fellowship. Working for 2-3 years as Dr. Nelson has proposed in the field of hospital medicine is not additional training, it is just additional practice. What is the formal training that the Society of Hospital Medicine proposes to qualify someone as a Board-certified hospitalist? Is it likely that young doctors are going to want to add on an additional 2 or 3 years of training beyond their internal medicine residency before they can start paying off their medical school loans? What will this training actually entail, and how will it merge with the internal medicine training programs that already exist?

I would point out that residents in fact are hospitalists in training. Certainly the vast majority of their clinical experience occurs in the hospital. Except for primary care residencies, I would estimate that 2/3 of the clinical care that internal medicine residents experience is in the hospital.

4) What about the primary care doctor or hospitalist who wants to switch careers?

Is the Society of Hospital Medicine going to require that a physician who has been in practice for 5 or 10 years and decides to switch to hospital medicine go through further training? Is that likely to occur? Alternatively, what about the hospitalist who gets tired of that field and wishes to become a primary care doctor? Might not office-based internists move to create their own specialty and thereby exclude hospitalists from work in that setting?

5) What about the malpractice risks that a new specialty will create?

Let’s imagine a world in which there are internists certified as hospitalists or as primary care physicians. Imagine this malpractice scenario. An office-based doctor caring for his/her own patients in the hospital is sued for some issue or another. The plaintiff attorney standing near the jury faces the doctor and asks “Doctor [he sighs, looking gravely serious], I understand there is a subspecialty in hospital medicine. Are you [now facing the jury] certified in that specialty? The doctor responds “No.” The attorney [turning abruptly back towards the nervous doctor] asks “No? Why not?” Let’s imagine another scenario. A hospitalist working part-time in an office-based practice 1 or 2 days a week faces a similar malpractice situation where he or she is sued. Attorney: “Doctor, I understand there is a subspecialty in primary care medicine? Are you certified in that specialty? Doctor: “No.” Attorney: “No? Why not?”

6) Why create more tests and expenses?

Enough said!

7) Do you want to bite the hand that feeds you?

In our hospital the vast majority of hospitalist admissions are from primary care doctors. Try to eliminate their admitting privileges and see what happens. It will be like the Flu vaccine fiasco this year. There is little vaccine available, but now everyone who has never gotten it in the past is asking for it. My guess is that most primary care doctors will protect their privileges and start admitting and caring for their own patients.

Why don’t we consider a more modest proposal? Here are three ideas.

First, identify areas of expertise that hospitalists actually develop. For instance, can they become procedural experts? Certainly the performance of lumbar punctures, thoracenteses, paracenteses, and central lines is something that most office-based doctors are not comfortable in carrying out any longer. Can we help create credentialing for these important procedures? That would go a long way towards initiating a set of skills that differentiates a hospitalist from an office-based doctor. Why not become a credentialing society for performance of these and other procedures? Monitoring numbers of procedures might constitute one measure, for example, of how to initiate credentialing. For instance, most centers no longer allow a cardiologist who has not performed a certain number of cardiac catheterizations a year to maintain privileges for that procedure. This does not seem discriminatory. It seems wise. I do not think office-based doctors would view credentialing for procedures as discriminatory.

Secondly, what about working to modify existing internal medicine training to perhaps provide added qualifications within hospital medicine for residents committed to the field? The board exams might actually differ then for primary care residents and for those interested in hospital medicine.

Thirdly, what about concentrating efforts on recertification? My guess is that very few residents coming out of practice would not feel qualified to take the hospital medicine or the ambulatory portion of an internal medicine exam. On the other hand, 10 years later during recertification many office-based doctors will not feel qualified to take an exam that emphasizes the treatment of vancomycin-resistant enterococci or management of cardiac arrests. Perhaps the recertification exam is the time to ask doctors to differentiate themselves. Some may wish to maintain certification in both hospital-based and ambulatory care, while others may choose one path or the other.

SHM has become the great organization it is in part because it reached out to hospitalists working in both community and teaching hospitals. Can we not bridge the gap with our office-based colleagues as well? In the field of internal medicine are we going to set ourselves up to become blue and red states? How about a nice shade of violet?

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